Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve continued inpatient behavioral health treatment from May 02, 
2023, forward (99213). 
 
You asked the Plan to pre-approve continued inpatient behavioral health treatment. You say that if the enrollee 
were to be discharged at this time, he would be high risk for rapid readmission due to continued medication 
adjustments occurring, history of medication noncompliance, and limited support system. The Plan denied your 
request. The Plan says that the enrollee does not meet criteria for behavioral health inpatient hospitalization. 
 
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 
treatment. Our reviewer says that the service is not medically necessary. Our physician reviewer found based 
upon review the records provided it was expected this enrollee would improve in a reasonable period of time 
beyond the dates in question as although he was not showing any dangerousness to self or others, auditory or 
visual hallucinations he was hyper and showing mood lability. It did 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 although he did not have any suicidal or homicidal thoughts, auditory or visual 
hallucinations he was showing mood lability. The health plans denial of continued inpatient psychiatric 
services appears inappropriate. This enrollee did require inpatient mental health treatment beyond the dates in 
question as although noted above as he was not a danger to himself or others and did not have any delusions, 
auditory or visual hallucinations he was showing mood lability and was hyperverbal. It did appear that active 
treatment was taking place beyond the date in question. It did 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. We are 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 meet the criteria for treatment in an acute inpatient mental health treatment beyond 
the date in question of May 2, 2023, forward and could not have been treated in a lesser restrictive setting as 
although he was not showing any suicidal or homicidal ideation, auditory or visual hallucinations, delusions and he was showing mood lability and hyperverbal interaction. The enrollee's medication was changed in 
active treatment was continuing. 
 
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 treatment have been met. Therefore, we 
decided that the Plan has to pre-approve continued inpatient behavioral health treatment from May 02, 2023, 
forward (99213).  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.