Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued inpatient psychiatric care after June 10, 2023. 
 
You asked the Plan to pre-approve continued inpatient psychiatric care. You say that the patient continues to be 
a safety risk in the community. The Plan denied your request. The Plan says continued inpatient mental health 
care after June 10, 2023, is not medically necessary. The patient does not need 24-hour care for safety, a 
significant threat for harm, or the presence of hallucinations.  
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 psychiatric care. 
Our reviewer says that continued inpatient psychiatric care is not medically necessary. Our physician reviewer 
found this 42-year-old male was admitted to the acute inpatient psychiatric hospitalization on June 1, 2023, 
with Unspecified Psychosis Not Due To Substance or Known Physiologic Condition. Based 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. 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 patients condition or for the purpose of diagnosis. This patient was treated under an individualized 
treatment plan found in the record. It appears that the services were supervised and evaluated by a physician. 
Based upon review the records provided, this patient does not meet the criteria for treatment in an acute 
inpatient mental health treatment beyond the date in question of June 10, 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 psychiatric care have not been met. Therefore, we decided 
that the Plan does not have to pre-approve continued inpatient psychiatric care after June 10, 2023.