Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued inpatient mental health care after May 27, 
2023. 
 
You asked the Plan to pre-approve continued inpatient mental health care. You say that continued inpatient 
psychiatric care is medically necessary as the patient has ongoing, worsening depression and anxiety. The Plan 
denied your request. The Plan says continued inpatient mental health services are not medically necessary as of 
May 27, 2022. The patient can be managed at a lower level of care.  
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 64-year-old female was admitted to the acute inpatient psychiatric hospital on May 11, 
2023, with major depressive disorder, recurrent, severe without psychotic features, dependent personality and 
cognitive dysfunction. 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. This patient was treated under an individualized treatment 
plan found in the record. 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 May 27, 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 after May 27, 2023.