Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Major Depressive Disorder.
Treatment inpatient level of care.
The insurer denied coverage for inpatient level of care.
The denial is overturned.

The patient is a female admitted in the pediatric unit due to suicidal thoughts and worsened depression and homicidal thoughts including suicidal plan to stab herself or someone else. She reportedly had depressed mood, crying, sleeping problems, anxiety, panic attacks, and tremors. She reportedly had a recent suicide attempt in which she put a knife to her throat and threatened to kill herself and had a recent hospitalization. The patient had a diagnosis of major depressive disorder. She was put on 1:1 constant observation and took Abilify, Depakote, and Neurontin. She was transferred to a psychiatric hospital. 

The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Suicidal Behaviors reports that patients with suicide attempts are at high risk of suicide. Suicide attempts are the single most reliable predictor of suicide. It also states that patients with suicidal plan or intent are in need of hospital treatment. 

This patient was considered a high-risk patient who had a recent reported suicide attempt by putting a knife to her throat and threatening to kill herself a few weeks prior to admission which resulted in a hospitalization, and she was reporting suicidal plan and homicidal plan to stab herself or someone else while reporting depressed mood. She also reportedly had a minimal support system and a strained relationship with her family. She had medication changes including taking Abilify, Depakote, and Neurontin and was on 1:1 observation. The psychiatric consultant reported that she was considered a danger to self and in need of 24-hour inpatient psychiatric hospital treatment, so she was transferred to the psychiatric hospital when the bed became available. She required 24-hour hospital treatment still as she was considered a danger to self and a high risk for suicide if not in this hospital.

The APA Practice Guidelines for the Treatment of Patients with Suicidal Behaviors reports also that patients may require more time in the hospital to better assess suicide because they sometimes do not tell the truth regarding their suicidal thoughts in order to leave the hospital and that observation in the hospital is appropriate to better ensure their safety. This patient was considered a high-risk patient and required the days in this hospital in the pediatric unit until discharged to an inpatient psychiatric hospital. She was on 1:1 observation and had psychotropic medication changes so she had an active psychiatric treatment plan even in the pediatric unit. 

Also, the APA Practice Guidelines for the Treatment of Patients with Major Depressive Disorder reports that patients with severe depressive symptoms, suicidal or homicidal plan or intent or attempts, or inability to adequately care for basic needs are in need of hospital treatment. 

In this case this patient had a recent reported suicide attempt in which put a knife to her throat threatening to kill herself and had suicidal plans to stab self or others on admission to the pediatric unit while still reporting depressed mood. Notes reported depressed mood still throughout the hospital stay on the pediatric unit and she was considered a high-risk patient in need of 24-hour hospital treatment in this hospital until transfer to the psychiatric hospital. 

Inpatient hospital treatment was medically necessary as the medical records provided enough specific evidence to support that she did require 24-hour hospital treatment. It did not appear that the health care plan acted reasonably or in the best interests of the patient.

The insurer's denial of coverage for the inpatient level of is overturned. Medical necessity is substantiated.