Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Psychosis

Treatment: Inpatient admission

The insurer denied coverage for inpatient mental health admission

The denial is upheld.


This adult male reportedly was admitted involuntarily to an inpatient treatment hospital setting due to a psychotic episode. He reportedly had paranoid delusional thinking, erratic behavior, psychomotor agitation, incoherent language, disorientation, was unkempt, had poor eye contact, decreased motivation, difficulty planning or doing activities, had decreased pleasure, flat affect, and had been using cannabis. It was reported that his toxicology was positive for cannabis. He reportedly had other reported inpatient admissions. He reportedly had diagnoses of Schizophrenia, Schizotypal Personality Disorder, and Cannabis Induced Psychotic Disorder. He reportedly took antipsychotic medication (Amisulpride), Valproate, Fluoxetine, and Hydroxyzine. 
 
This reviewer agrees with the decision to deny coverage and for the residential level of care for this inpatient mental health services treatment as there were no medical records for review. There were medical records for previous admission which stated that this was an involuntary admission due to a psychotic episode and poor functioning and psychotic symptoms including paranoid delusional thinking, erratic behavior, psychomotor agitation, incoherent language, disorientation, unkempt, poor eye contact, decreased motivation, difficulty planning or doing activities, decreased pleasure, flat affect, and cannabis use. There was a letter asking for extension of his hospital stay to monitor clinical response to psychotropic medications, drug interactions, and to provide continuity in the environment protected by psychosocial interventions of individual and group therapy. There also were records for a subsequent inpatient hospital stay which reported psychotic symptoms again and stated that he had the past inpatient mental health treatment from other hospitalizations in the United States. However, there were no medical records stating the patient's clinical symptoms and presentation for the current admission. The documentation submitted for review did not provide specific evidence to support the need for continued inpatient mental health treatment. 

The Milliman Care Guidelines (MCG) Behavioral Health-Adult-Inpatient Level of Care guidelines reports that one needs one of the following: presenting as an imminent danger to self, imminent danger to others, severe psychiatric or behavioral symptoms, a severely dysfunctional living including inability to care for self, unwilling to participate voluntarily, or if a less restrictive level of care is not feasible meet criteria for inpatient behavioral health level of care. The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Schizophrenia reports that patients with hallucinations, delusional thinking, disorganized behavior, suicidal or homicidal plan or intent, agitation, or aggressive behavior are candidates for inpatient treatment. 

 In this case there were no reports of further serious psychotic symptoms such as delusions, hallucinations, or disorganized behavior, suicidal or homicidal ideation, intent, or plan, manic symptoms, aggressive, threatening, self-injurious, or agitated behavior, withdrawal symptoms or acute medical instability. 

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for inpatient mental health services at a residential level of care is not substantiated.