Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued inpatient mental health care as of November 
15, 2023, 
 
You asked the Plan to pre-approve continued inpatient mental health care. You say that the enrollee is 
homeless and is not safe to discharge her with no resources. The Plan denied your request. The Plan says the 
enrollee is stable with no suicidal or homicidal ideation. Continued inpatient admission as of November 15, 
2023, is not medically necessary, and care can be provided in a lower-level setting.  
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 mental health care. 
Our reviewer says that continued inpatient mental health care is not medically necessary. Our physician 
reviewer found this 67-year-old female was admitted to acute inpatient psychiatric hospitalization on 
November 4, 2023, with Major Neurocognitive Disorder unspecified with Behavioral Disturbance. Based upon 
review of the records provided, it was not expected this enrollee would improve in a reasonable period of time 
for the dates in question as she did not have suicidal or homicidal ideation, auditory or visual hallucinations. 
The patient was compliant with treatment while not showing any acute threats to 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 she did not have dangerousness to self or others and 
was compliant with her treatment. The health plans denial of continued inpatient psychiatric services is 
appropriate. This enrollee did not appear to require inpatient mental health treatment beyond the date in 
question as she was not a danger to herself or others and does not have 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 
were reasonably expected to improve the patients condition or for the purpose of diagnosis beyond the date in 
question. I am unable to find an individualized treatment plan, however the entire record is not present. It did 
appear that the records were supervised and evaluated by a physician. Based upon review the records provided 
for the admission of this patient does not meet the criteria for November 15, 2023, forward as this patient was 
not shown to be a danger to herself or others, delusions, auditory or visual hallucinations noted. She was 
cooperative/compliant with treatment while not showing any threats the 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 mental health care have not been met. Therefore, we 
decided that the Plan does not have to pre-approve continued inpatient mental health care as of November 15, 
2023,