Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve continued inpatient psychiatric hospital services. 
 
You asked the Plan to pre-approve continued inpatient psychiatric hospital services. You say that the enrollee's 
stay in an inpatient behavioral health facility is medically needed.  The Plan denied your request. The Plan says 
that the records do not show that the enrollee is receiving active treatment for her condition and that the care 
has been custodial. Continued stay at the psychiatric inpatient hospitalization level of care for this admission is 
not medically necessary beginning June 10, 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 inpatient psychiatric hospital 
services. Our reviewer says that the service is medically necessary. Our physician reviewer found the enrollee 
was admitted to the acute inpatient psychiatric hospitalization on May 15, 2023, with delusional disorder. 
Based upon review the records provided, it was expected this enrollee would improve in a reasonable period of 
time for the dates in question as although she did not have suicidal or homicidal ideation, auditory or visual 
hallucinations, she did have delusional thinking. It did 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. The health plans denial of continued inpatient psychiatric services is inappropriate. This enrollee 
did appear to require inpatient mental health treatment beyond the date in question as although she was not a 
danger to herself or others and does not have auditory or visual hallucinations, she did have delusional 
thinking. It did appear that active treatment was taking place beyond the date in question as noted in the 
documentation. It did appear that the services were reasonably expected to improve the enrollee's 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 enrollee does meet the criteria for 
June 10, 2023, forward as although this enrollee was not shown to be a danger to herself or others, auditory or 
visual hallucinations noted, she did have delusional thinking that require treatment. 
 
 
 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 hospital services have been met. Therefore, we 
decided that the Plan has to pre-approve continued inpatient psychiatric hospital services.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.