Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Worsening depressive and anxiety symptoms
Treatment:  Continued inpatient admission

The proposed treatment was not medically necessary. 

This female patient with a past history of major depressive disorder and social anxiety disorder presented with worsening depressed mood and suicidal ideation with multiple plans, including jumping out of a window and shooting herself.  Her symptoms were consistent with her primary diagnosis of borderline personality disorder. 
The patient had no prior psychiatric hospitalizations and no known suicide attempts, but she did have a history of self injury by cutting.  At the time of admission the patient was dysphoric with suicidal ideation and self-injury impulses.  She was considered to be at acute risk for suicide and self-harm but abstained from self injury in the hospital, even after close observation was discontinued. 
Her medications included Prozac 40 milligrams (mg) daily, augmented with Abilify 2mg in the morning and 5mg at bedtime, trazodone 75mg at bedtime, Ativan 1mg every six hours as needed and Atarax 50mg every six hours as needed for anxiety.  She was provided individual, group, and milieu therapy with a goal of symptom reduction.
The patient made slow, inconsistent progress during the first three weeks of hospitalization.  By the fourth week the patient denied self harming behavior but continued to have thoughts of shooting herself, cutting herself, overdosing, or hanging herself.  She stated however that she would not act on these because she would like to come off close observation.  She felt that perhaps she was feeling a little better but continued to endorse feelings of depression, hopelessness, and guilt.  She was calm and cooperative with treatment.  She agreed to an increase of Prozac to 60mg daily.
After one month of treatment, she began improving rapidly.
On the fifth week, a physician's progress note reported that the patient felt that she was having "the best day yet."  The patient continued to endorse feeling sad at times but felt that it was more of a transient sadness.  She got along well with peers and began playing the piano again which had been a passion of hers.  She reported fleeting suicidal and self-harm thoughts but no urges.
A psychiatry note reports that the patient felt "really good" after being taken off close observation.  She had transient thoughts of self harm by head banging but denied any intent to act on them.  She was more hopeful and future oriented.
On the first day under review, the patient reported that her mood was "up and down."  She denied suicidal plan or intent.  She complained of anxiety.  She was well-related and calm but somewhat anxious.  Her insight and judgment were considered impaired but improving.
On following two days, the patient felt less anxious, less depressed, more hopeful, and highly motivated for outpatient treatment.  She denied suicidal ideation.  She was engaged in comprehensive safety planning prior to discharge.
By the first day under review, the patient's mood had improved considerably. She was future oriented and she consistently denied suicidal ideation.  Nothing in the documentation reviewed indicates that she could not have been treated safely and effectively at a less intensive level of care.