Appeal type: Medical necessity
Decision: Overturned

Psychosis
Mental health inpatient

The case involves an adult who was admitted on early 2019 to acute inpatient psychiatric services for mood disturbance and psychosis. The patient was brought in by police and emergency medical services due to threatening behavior towards  mother and sister's boyfriend with whom the patient  lived. Patient had been acting bizarre in the two months prior to presentation and had been discharged from inpatient level psychiatric treatment just two days prior to presentation. The patient reported increasing symptoms of depression in the context of symptoms of psychosis that included paranoid thought content and the belief that the mother had stolen  money. The patient had become increasingly depressed following a divorce 3 months earlier. Moreover, the patient reported not taking medication, Latuda, that had been prescribed. And,  mother had kicked him out of the home and filed a restraining order leaving the patient homeless.
The patient presented to the emergency department, and was subsequently admitted after medical clearance that included physical examination, laboratory assessment and electrocardiogram (EKG).  Assessment included normal laboratory findings and a positive drug screen consistent with  intermittent use of cannabis (marijuana). Patient had co-occurring alcohol use disorder and had spent nine months in rehabilitation treatment in the previous year with a reduction of alcohol use, but continued daily use of two beers.
The patient has a history of psychiatric treatment and hospitalizations for schizophrenia and depressive disorder. Also had a history of medication non-adherence and co-occurring substance use disorders with alcohol and cannabis, as noted. Patient had been using one blunt of marijuana intermittently.  The patient was psychotic and cognitively impaired with thought blocking and paranoid thought content and depressive ruminations with regard to the ex-spouse. Patient was guarded, but cooperative with poor eye contact, displayed depressed mood with anxiety, nervousness, apprehension, tension, irritability, and excessive worry, and, indicated that patient was having aggressive impulses, but denied active suicidal or homicidal intent. Again, patient demonstrated paranoid delusions and intense ruminations including grief related to the recent divorce. Patient had decreased concentration, energy, sleep, and volition. The patient's treatment plan included safety monitoring and medication targeting mood disturbance and psychosis, as well as therapy and psychoeducation provided in the milieu. Haldol and as needed (prn) Ativan were prescribed for acute agitation and anxiety. Other medications included Atarax and Benadryl for anxiety and insomnia. The patient refused medications indicating did not need them except for Benadryl which the patient did take to enhance sleep. Discharge planning occurred and disposition to the community with intensive services had been arranged with therapeutic shelter and assertive community treatment. The patient was discharged with follow-up for the co-occurring psychiatric and substance use disorders with disposition to the shelter and recommendations for follow up for general medical care of obesity and smoking cessation. The HP determination of medical necessity is overturned in whole. The patient's continued inpatient mental health treatment is reasonable and in the best interest of the patient; Patient had severe symptoms of depression and psychosis complicated by substance abuse and medication non-adherence and decline in functioning. Patient had deteriorated to the point that he was a safety risk with intrusive thoughts that included aggressive impulses. Moreover, the patient's co-occurring substance use disorder was significant, and the patient had clinical features and continued mental status findings that posed a serious safety risk during the time interval under review. The patient could not have been safely or effectively managed during the time interval under review at a lower level of care.
The patient's severity of symptoms, and inability to benefit from treatment at a lower level of care, functional decline, and safety issues related to persistent symptoms of psychosis and mood disturbance were clinical factors and treatment dimensions that necessitated acute inpatient hospital care, structure, and monitoring as proposed through discharge. The medication management and safety monitoring together with attention to the precipitating issues in this case were medically necessary; the intensity of services and safety issues in this case could not have been effectively addressed or managed at a lower level of care.