Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued inpatient behavioral health. 
 
You asked the Plan to pre-approve continued inpatient behavioral health. You say that continued care is 
medically necessary for the enrollee. The Plan denied your request. The Plan says the continued inpatient 
behavioral health level of care is not medically necessary. 
 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. 
Our reviewer says that the service is not medically necessary. Our physician reviewer found the enrollee was 
involuntarily admitted to the acute inpatient psychiatric hospitalization on June 8, 2023, with unspecified 
psychosis not due to substance or known physiologic condition and unspecified depression. Based upon 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. 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 enrollees 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 the records provided, this enrollee does not meet the 
criteria for treatment in an acute inpatient mental health treatment beyond the date in question of July 8, 2023, 
forward 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 have not been met. Therefore, we decided 
that the Plan does not have to pre-approve continued inpatient behavioral health.