Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Psychosis. 
Treatment: Continued stay. 

The insurer denied coverage for continued stay. 

The denial is overturned. 

This patient was admitted to the hospital for altered mental status, psychotic symptoms including command auditory hallucinations, and paranoid thinking and behavior, responding to internal stimuli, catatonic behavior including not responding or communicating, minimal social interaction, and inability to attend school. He reportedly had decreased psychomotor activity also. He reportedly had electroconvulsive treatment (ECT) and Ativan for catatonia. He reportedly also went to court for ECT treatment. He was on 1:1 observation. He continued to have ECT and medication management until discharged. 
  
The Milliman Care Guidelines (MCG) Behavioral Health Inpatient Level of Care Adult criteria reports that a patient needs to present as an imminent danger to self, imminent danger to others, with severe psychiatric or behavioral symptoms, have a severely dysfunctional living including inability to care for self, unwillingness to participate voluntarily, or a less restrictive level of care is not feasible meet criteria for inpatient behavioral health level of care. The InterQual Behavioral Health-Adult and Geriatric Psychiatry-Inpatient medical necessity criteria reports that if one has assaultive behavior within 24 hours, catatonia, command hallucinations to harm self or others, destruction of property with poor impulse control within 24 hours, disorganized behavior, unstable eating disorder, fire setting, homicidal or suicidal attempt within 24 hours, suicidal or  homicidal ideation with high risk for an attempt, mania, risk of harm to self or others, non-suicidal self-injury and continued danger to self, positive psychotic symptoms with risk of harm to self or others, post-traumatic stress disorder (PTSD) with risk of harm to self or others, psychomotor agitation and potential for violence, severe social withdrawal and refusing treatment, unavailable support or inability to provide needed care and supervision and there is acute deterioration in functioning then meet criteria for inpatient treatment. 

This patient had severe psychiatric symptoms requiring 24-hour hospital treatment including psychotic symptoms of catatonia which requires inpatient hospital treatment and also had reports of command auditory hallucinations, and paranoid thinking and behavior, responding to internal stimuli, catatonic behavior including not responding or communicating, minimal social interaction, and inability to attend school. The patient reportedly had developmental delays consistent with intellectual disability. He reportedly continued to have reported psychotic symptoms including catatonia until discharged and had electro-convulsive therapy (ECT) and medication management for psychotic symptoms, so he required 24-hour hospital treatment throughout his hospital stay. 

Notes reported that he was unable to think or answer questions and was somnolent with decreased cognition and attribution, increased confusion, impaired judgment, poor insight, catatonic state, unable to care for self, unable to communicate or verbalize, and disorientation to time.  Notes reported that he was not responding to questions and was unable to assess thought content or thought process. Other notes reported that he was largely mute and continued to have mannerisms and stereotypies. Notes reported that he was smiling inappropriately and giggling, had decreased psychomotor activity, and was unable to assess thought process or content. Notes reported that he still had catatonia. Documentation reported that he was ignoring attempts at communication, was not demonstrating thought process and content, and had treatment for catatonia. 

He was discharged with Risperidone and Memantine and had 1:1 observation. This patient continued to have psychotic symptoms including catatonia with inability to care for self and required ECT and medication management throughout the hospital stay until discharged. As a result, the recommendation is to overturn 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, with sound clinical judgment, or in the best interests of the patient then. 

The health plan did not act reasonably with sound medical judgment in the best interest of the patient. 

The insurer's denial of coverage for continued stay is overturned. Medical necessity is substantiated.