Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have 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 is 
currently and continues to remain in an acute psychiatric hospital, her last covered day was August 6, 2023. 
The Plan denied your request. The Plan says the request does not meet Medicare guidelines because the records 
do not show dangerous behaviors, a need for inpatient level of monitoring or treatment, inability to function at 
a lower level of care, or serious medical issues requiring inpatient 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 psychiatric hospital 
services. Our reviewer says that the service is not medically necessary. Our physician reviewer found the 
enrollee was admitted to the acute inpatient psychiatric hospitalization on July 25, 2023, with Schizoaffective 
Disorder, Posttraumatic Stress Disorder, Panic Disorder and attention deficit hyperactivity disorder (ADHD). 
Based upon review, 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 enrollee 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 enrollees condition or for the purpose of diagnosis beyond 
the date in question. The reviewer is 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 not meet the criteria for August 7, 2023, forward as 
this enrollee 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 psychiatric hospital services have not been met. Therefore, 
we decided that the Plan does not have to pre-approve continued inpatient psychiatric hospital services.