Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Attempted suicide 
Treatment: Continued inpatient hospital admission
The continued inpatient admission was medically necessary.  

The patient is a female with a history of mental illness who received treatment at St. Barnabas Hospital.

The patient has a history of mental illness and is diagnosed with depression and anxiety.  She has a history of medical illness including diagnosis with obesity.  There is a history of substance abuse including opiates and cocaine and current treatment with methadone.  There is a history of having served jail time and she is currently on Parole.  There is a history of being married and marital fighting as a notable stressor.

The patient ingested 30 tabs of an antidepressant medication as a suicide attempt and was brought to the hospital for medical evaluation by EMS.  She was noted to have metabolic abnormalities.  She was noted to have depressed mood and suicidal thoughts with anhedonia and depression.  She was medically cleared for psychiatric admission and was monitored for symptoms of serotonin syndrome and orthostatic hypotension.

The patient was treated by a multidisciplinary team including therapy, nursing, and psychiatry staff.  She received group and individual therapy.  She received a psychopharmacology evaluation and was started on Fluoxetine ten milligrams (MG) by mouth (PO) daily.  Methadone was continued and Clonazepam was continued.  Her Fluoxetine was increased to 20MG PO daily.  Her family was involved in discharge planning.

The patient was discharged with a plan for outpatient psychiatric follow up.

The patient represented an acutely elevated risk of dangerous behaviors and there was no less-restrictive treatment environment appropriate.  The acute risk factor of medication changes and recent suicide attempt with the chronic risk factors of potentially dangerous behaviors suggest that the patient would have been at an acute risk of self-injurious behaviors (including but not limited to suicide) were she to have been discharged from the inpatient hospital setting.  The patient was discharged from the inpatient psychiatric hospital setting as soon as a less-restrictive treatment setting was appropriate.  

The patient represented an elevated risk of dangerous behaviors including aggressive behaviors, self-injury, and suicide, and there was no less-restrictive treatment environment appropriate.  Therefore the treatment was medically necessary.  While the patient was not endorsing active suicidality or homicidality, the patient remained with significant symptoms.  The patient had multiple static risk factors for potentially dangerous behaviors including prior suicide attempt, forensic and substance abuse history, and diagnosis with a severe mental illness.  Therefore the patient represented a chronic risk of potentially dangerous behaviors.  The fact that patient remained with ongoing medication changes was acute risk factor for dangerous behaviors.  Furthermore, the fact that there was no less-restrictive environment of care appropriate suggests that ongoing inpatient psychiatric hospitalization was medically necessary and should be covered by the patient's health plan.