Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued inpatient behavioral health services. 
 
You asked the Plan to pre-approve continued inpatient behavioral health services. You say that the enrollee has 
alcohol mental health disorder, anxiety issues and he is still having problems with alcohol usage. He needs 
continued inpatient monitoring. The Plan denied your request. The Plan says the enrollee is socializing with 
peers, attending classes, able to verbalize lifestyle changes and needs to maintain sobriety. There are no safety 
concerns. It appears the enrollee's needs can be met at an alternative level of care.  
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve continued inpatient behavioral health 
services. Our reviewer says that the service is not medically necessary. Our physician reviewer found upon 
review of the records provided, it was not expected this enrollee would improve in a reasonable period of time 
beyond the dates in question as he was not showing any dangerousness to self or others, auditory or visual 
hallucinations and without aggressive behaviors while not showing any acute threats of safety. The enrollee 
was cooperative and compliant with medication. It did not appear medically necessary and reasonable to have 
psychiatric care provided at the acute inpatient level of care rather than a lower level of care beyond the dates 
in question as he did not have any suicidal or homicidal thoughts, auditory or visual hallucinations or abnormal 
behaviors. The health plans denial of continued inpatient psychiatric services appears appropriate. This 
enrollee did not require inpatient mental health treatment beyond the dates in question as noted above as he was 
not a danger to himself or others and did not have any delusions, auditory or visual hallucinations. It did not 
appear that active treatment was taking place beyond the date in question. It did not appear that the services for 
the dates in question were reasonably expected or medically necessary to improve the enrollee's condition or 
for the purpose of diagnosis. The reviewer is unable to find an individualized treatment plan however the entire 
record is not present. It appears that the services were supervised and evaluated by a physician. Based upon 
review the records provided, this enrollee does not meet the criteria for treatment in an acute 
inpatient/detoxification treatment and could have been treated in a lesser restrictive setting as he was not 
showing any suicidal or homicidal ideation, auditory or visual hallucinations, delusions and was not showing 
any behaviors or aggression being cooperative and compliant while not showing any acute threats to safety. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued inpatient behavioral health services have not been met. Therefore, we 
decided that the Plan does not have to pre-approve continued inpatient behavioral health services.