Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Depressive symptoms and multiple substance use  

Treatment: Inpatient mental health treatment

The insurer denied coverage for continued inpatient mental health treatment. The denial was reversed.

This patient is a female who was admitted to this inpatient mental health treatment in this hospital due to worsened depressive symptoms and multiple substance use. She had worsened depressed and irritable mood, agitation, anhedonia, low appetite, paranoid delusions, anger, and noncompliance, was loud, fearful, and had poor insight and judgment. She was using multiple substances. She had a diagnosis of Major Depressive Disorder. She was prescribed the medications: Wellbutrin and Abilify. She was discharged to an inpatient substance rehabilitation treatment.

The insurer denied coverage for continued inpatient mental health treatment in this hospital as not medically necessary treatments. This reviewer disagrees with the decision to deny coverage for inpatient mental health treatment in this hospital as not medically necessary as the chart notes did provide enough specific evidence to support that she still required 24 hour hospital treatment. The APA Practice Guidelines for the Treatment of Patients with Major Depressive Disorders reports that treatment settings for patients with major depressive disorder include a continuum of possible levels of care and in general, patients should be treated in the least restrictive setting that is most likely to prove safe and effective. It states that the psychiatrist should choose an appropriate site of treatment after evaluating the patient's clinical condition, including symptom severity, co-occurring conditions, level of functioning, and available support system. The estimated degree of risk to self and to others is another significant determinant of treatment setting. The decisions about treatment setting should also include consideration of the patient's ability to adequately care for him- or herself, provide reliable feedback to the psychiatrist, and cooperate with treatment of the major depressive disorder.

In this case this patient was unable to care for herself adequately if not in 24 hour treatment, as she had depressive symptoms and dangerous behavior. She had noncompliance and a history of using multiple serious substances. She still was agitated and loud during the denial period and could not be safely discharged to outpatient treatment as she needed to be discharged from this 24 hour hospital setting to a 24 hour inpatient substance rehabilitation treatment. She was a high risk for relapse without the 24 hour supervision and structure of a therapeutic inpatient substance rehabilitation setting. The notes on a specified date reported that she was screaming at a visitor, was loud, and agitated. The notes on another date reported that she was loud, verbally abusive, threatening to punch staff in the face, irritable, and argumentative. She was intrusive and then discharged to the inpatient substance rehabilitation setting. She was considered unable to care for herself without these 24 hour supports and still had agitation, threatening behavior, and mood symptoms until discharge putting herself and others at risk of danger. 

As a result, the determination to reverse the previous decision and approve coverage for continued inpatient mental health treatment in this hospital. It did not appear that the health care plan acted reasonably or in the best interests of the patient.  .

Based on the above, the medical necessity for inpatient hospital admission is substantiated.  The insurer's denial is reversed.