Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continuation of inpatient mental health admission. 
 
You asked the Plan to pre-approve continuation of inpatient mental health admission. You say that the enrollee 
is on the spectrum and cannot care for himself. He continues to require hospitalization. The Plan denied your 
request. The Plan says continued inpatient mental health care is not medically necessary. The patient was 
admitted on August 13, 2023, and as of October 13, 2023, he was ready to discharge. The only reason that the enrollee is still in the facility is due to issues with him finding a new living situation. As of this date, the 
enrollee is safe and stable and no acute treatment is needed or planned. 
 
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 continuation of inpatient mental health 
admission. Our reviewer says that continuation of inpatient mental health admission is not medically necessary. 
Our physician reviewer found this 25-year-old male was admitted to the acute inpatient psychiatric 
hospitalization on August 13, 2023, with Autism Spectrum Disorder and Posttraumatic Stress Disorder. Based 
upon review the records provided, it is not expected this enrollee will improve in a reasonable period of time 
beyond the dates in question as he is 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 does 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 does 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 does not require inpatient mental health 
treatment beyond the dates in question as noted above as he is not a danger to himself or others and does not 
have any delusions, auditory or visual hallucinations. It does not appear that active treatment is taking place 
beyond the date in question. It does not appear that the services for the dates in question are reasonably 
expected or medically necessary to improve the patients condition or for the purpose of diagnosis. The doctor 
was 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 not meet the criteria for treatment in an acute inpatient mental health treatment beyond the date in 
question of October 13, 2023, forward and could be treated in a lesser restrictive setting as he is not showing 
any suicidal or homicidal ideation, auditory or visual hallucinations, delusions and is not showing any 
behaviors or aggression being cooperative and compliant while not showing any acute threats to safety as he 
awaits placement in the group home. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continuation of inpatient mental health admission have not been met. Therefore, 
we decided that the Plan does not have to pre-approve continuation of inpatient mental health admission.