Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Mental Health
Treatment: Mental health Inpatient
The insurer denied the Mental Health Inpatient Stay
The health plan's determination is overturned in whole.

The inpatient mental health stay for the dates in question is medically necessary for this patient. This case involves a patient who was medically screened in the emergency department and admitted for acute inpatient psychiatric treatment. The patient had become increasingly depressed with suicidal ideation wanting to die and severe poly-substance use with deterioration in functioning culminating in presentation. Patient has a history of bipolar disorder and severe depressive episodes and psychiatric treatment with therapy and medications, as well as multiple psychiatric hospitalizations. The patient has a history of mood disorder best characterized as bipolar I disorder with manic and depressive episodes and multiple psychiatric hospitalizations for severe symptoms of the mood disorder and an unspecified anxiety disorder. Patient was receiving outpatient psychiatric treatment with medications, but had failed to follow up after the last psychiatric hospitalization.
The patient has a history of substance use disorders, as noted with active substance use and consequences of  use that includes legal charges, dropping out of college and unemployment. The mental status examination revealed sad affect and anxiety including apprehension, nervousness, tension, irritability, and excessive worry. Sleep, appetite, energy levels and volition were disturbed. The patient exhibited depressed mood with suicidal ideation, hopelessness and anhedonia. Patient was withdrawn with motor agitation. There was no psychosis or other signs of cognitive impairment or perceptual disturbance. Judgment was markedly impaired, and suicidal risk was judged to be moderately severe with poor control of impulses and limited insight together with  struggles with maintaining abstinence. The patient was admitted to inpatient level care with plans for close observation, safety monitoring, structured milieu therapy, and pharmacotherapy initially with olanzapine, bupropion and clonazepam, as well as vitamin and nicotine replacement therapy. The patient continued to exhibit severe symptoms of depression with dysphoria and sad affect. For the DOS in question , the patient had bouts of mood cycling with irritable dysphoria, distractibility and concentration problems, and disorganized thought production. The medications were titrated as clinically appropriate. The patient was discharged from inpatient level care with step down to the community and referral for clinically appropriate aftercare. The patient's presentation and clinical features included severe symptoms of a bipolar mood disorder, suicidal risk, and deterioration in functioning in the context of severe substance use disorder with several substances of abuse and daily use. The patient remained at risk for relapse or suicidal behavior during the time interval under review in view of the history of prior treatment episodes and severe symptoms of mood disorder. Additionally, a safe and clinically appropriate discharge plan and disposition was critical in this case to prevent re-hospitalization or immediate relapse together with the use of an atypical antipsychotic medication and continued use of the antidepressant medication and supplemental use of clonazepam. The patient could not have been expected to participate in treatment at a lower level of care during the time interval under review in this case scenario. The necessity for the continued inpatient level services reflects sound medical judgment in keeping with prevailing standards of professional practice, and with the published practice guidelines and criteria, referenced below, as well as New York State instruction for medical necessity reviews including the application of NY State Office of Alcoholism and Substance Abuse Services (OASAS) Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) 3.0 Guidelines concerning drug and alcohol use disorders.