Appeal type: Medical necessity
Decision: Overturned in Part

This is a patient with a chronic psychotic disorder best characterized as schizoaffective disorder, depressed type. The patient has a history of co-occurring substance use disorder with an opioid class substance of abuse. The patient presented to emergency services and was admitted for acute inpatient treatment of an exacerbation of the psychotic and mood disorder with anxiety, paranoia, and worsening symptoms of depression with suicidal ideation.
The mental status examination revealed suicidal ideation, suspiciousness with paranoid delusions, depressed mood, motor agitation, and disorganized thought processing. He had markedly impaired judgment together with limited insight and poor impulse control. He had morbid preoccupations indicating fear that he was in a movie and being filmed and was at risk to be harmed. He was anxious with irritability, nervousness, tension and worry. He had decreased concentration, energy, appetite and volition.
The patient has a past treatment history for schizoaffective disorder, depressed type; he had multiple prior psychiatric hospitalizations including one suicide attempt with an intentional heroin overdose. There were no acute general medical conditions in this case.
The patient was admitted to acute inpatient psychiatric services with close observation and safety monitoring; structured psychosocial programming; and pharmacotherapy with mood stabilizer and antidepressant and antipsychotic medications. His hospital course was complicated by severe symptoms of psychosis and persistent suicidal ideation with little progress. His medications were titrated, as clinically appropriate with a regimen of lithium, quetiapine, fluoxetine and clonazepam with adherence and tolerability.
The patient remained depressed with withdrawn behavior and continued psychosis and suicidal ideation. The treatment team focused on coping skills, attention to self-care and reality testing with active treatment of the mood and psychotic disorder with the medication and therapy and safety monitoring.
Ten days later, the patient was noted to be calm and cooperative with improved sleep, appetite and functioning. His mood was improved with only passive suicidal ideation. The patient was increasingly cooperative with care, compliant with milieu therapeutic activities, and, medication adherent with tolerability. He had been started on clozapine with the addition of Wellbutrin which produced improved mood that was subsequently okay despite persistent symptoms of anxiety. Going forward, the patient remained calm but anxious, cooperative and engaged in treatment with medication adherence and tolerability. Discharge planning had occurred with regard to a safe and clinically appropriate discharge plan and disposition.
 
The health plan's determination is overturned in part.
The proposed inpatient treatment is medically necessary, in part, as the patient required the structure of an inpatient level of care in order to remain safe and to administer continued treatment for his psychiatric disturbance while conducting an evaluation, and observing his functioning with titration and monitoring of his medication including tolerability and response to antipsychotic/mood stabilizing medication, clozapine together with lithium and antidepressant medications. It was medically necessary for the patient to continue to receive 24-hour monitoring in view of residual symptoms of psychosis, the mood disturbance, and risk for affective instability, and continued disturbance of thought.
However, acute inpatient mental health treatment was not medically necessary once the patient no longer required the structure of an inpatient level of care in order to remain safe or to administer continued treatment for the psychiatric disturbance, including administration and monitoring of medication that could have been arranged without the need for continued acute inpatient level services. It was not medically necessary for this patient to have 24-hour monitoring in view of his relative lack of impulsive behaviors, diminished symptoms of psychosis, and improvements in mood and daily functioning. There were no general medical issues or co-occurring substance use disorder complicating this case that would have required continued acute inpatient level services. Additionally, the inpatient stay during this time interval forward was not medically necessary in order to monitor the patient for at-risk behaviors, or to address the acute risk of relapse or medication non-adherence. The patient had access to services and treatment that could safely and effectively continue at a lower level of care with intensive services and a safety plan.