Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Depression, somatic preoccupations, irritable mood, and anxiety

Treatment: continued inpatient mental health treatment

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

This patient is a female was admitted to this inpatient mental health treatment in this hospital due to depression, somatic preoccupations, irritable mood, and anxiety. She had a past psychiatric hospitalization. She had a diagnosis of Schizoaffective Disorder, depressed type vs Major Depressive Disorder. She had no past suicide attempts, substance use, or violence. It was reported that her mother and son died. She took Depakote, Zyprexa, Duloxetine, Trazodone, and Propranolol and attended individual and group therapy. She was discharged at a later date.

The insurer denied coverage for continued inpatient mental health treatment in this hospital as not medically necessary treatment.

This reviewer agrees with the decision to deny coverage for continued inpatient mental health treatment in this hospital as the medical records did not provide enough specific evidence to support that she still only required this acute psychiatric hospital level of care or that he could not be safely and effectively treated in a less restrictive level of care. The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Major Depressive Disorders reports that the least restrictive level of care for safe and effective treatment is appropriate and that patients with suicidal plan or intent or behaviors, or inability to adequately care for basic needs are candidates for hospitalization. As of a specified date there were no reports of suicidal thoughts, plan, or intent, psychotic symptoms, severe depression interfering with her ability to care for basic needs, or acute medical instability. Also, she denied suicidal or homicidal ideation, plan, or intent, hallucinations, delusional thinking, side effects of medication, substance use or withdrawal. She had reports of linear thought process, her mood was a little better, and she had reports of fair insight and judgment. Notes on a specified date reported that she denied suicidal or homicidal ideation, plan, or intent, hallucinations, delusional thinking, denied hopelessness, remained in control, and had linear thought process, as well as fair insight and judgment. She remained in control and was compliant with medications. She was then discharged.  

As a specified date, the chart notes did not provide enough specific evidence that she was an imminent danger to self or others or was unable to adequately care for her basic needs. Also, as of then, there were no reports of specific identifiable or quantifiable treatment goals or objectives that could only be achieved in a 24- hour acute psychiatric hospital setting or that could not be achieved in a less restrictive setting.
As a result, uphold the previous decision and deny coverage for inpatient mental health treatment at this hospital. The health care plan acted reasonably and with sound medical judgment and in the best interests of the patient.

Based on the above, the medical necessity for the continued inpatient admission is not substantiated.  The insurer's denial is upheld.