Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued stay at the psychiatric inpatient 
hospitalization level of care. 
 
 
 
 You asked the Plan to pre-approve continued psychiatric inpatient care. You say that the severity of the 
enrollee's presenting signs and symptoms, the medical predictability of adverse events, the types and 
appropriateness of care that is available to the enrollee, the inpatient behavioral health hospital level of care is 
medically necessary, reasonable, and appropriate. Medical treatment for the enrollee cannot be achieved at a 
lower level of care. The Plan denied your request. The Plan says continued stay at the psychiatric inpatient 
hospitalization level of care for this admission is not medically necessary beginning April 27th, 2023. The 
service can be provided safely in other settings. 
 
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 psychiatric inpatient care. 
Our reviewer says that the service is not medically necessary. Our physician reviewer found based upon 
review, 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 enrollee's condition or for the purpose of diagnosis. This enrollee 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 enrollee does not meet the criteria for treatment in an 
acute inpatient mental health treatment beyond the date in question of April 27, 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 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 psychiatric inpatient care have not been met. Therefore, we decided 
that the Plan does not have to pre-approve continued stay at the psychiatric inpatient hospitalization level of 
care.