Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Mental Health/High Risk Suicide
Treatment: Mental Health: Inpatient
The health plan denied the inpatient mental health stay due to a lack of medical necessity. 
The health plan's determination is overturned.

This case involves an adolescent female admitted for acute inpatient psychiatric treatment. The patient was transferred from an acute care facility where she was treated for a Tylenol overdose and suicide attempt in the context of worsening symptoms of depression. The patient has a history of an unspecified mood disorder with depressive symptoms and rapid mood cycling and comorbid posttraumatic stress disorder related to finding her uncle dead of an overdose and witnessing domestic violence, and co-morbid anxiety symptoms of disorder. The patient has received therapy over the four years prior to admission. She has a history of suicidal behavior and self-harm with cutting. There is family conflict with her mother with whom she lives, and tension over the patient's sexual orientation. Additionally, the patient had been prescribed Lexapro, but the mother is opposed to antidepressant medication. The patient was admitted with plans for close observation, safety monitoring, structured milieu therapy, and pharmacotherapy with adjustments and with approval from the patient's mother. She received Clonidine and Melatonin. The patient became increasingly cooperative with treatment and more social with peers with improved mood and resolution of the hallucinations. From the dates in question forward, the focus of treatment was on the tension and stress within the family constellation focusing on the patient's indicated sexual orientation that was not accepted by the mother and other issues related to family functions. The patient received psychological testing that revealed probable traumatic brain injury prompting arrangements for an magnetic resonance imaging (MRI) of the brain and specialty referral. By the day of discharge, the patient's symptoms were mostly improved with better mood and less anxiety and improved sleep and functioning. She denied suicidal ideation, plan or intent.

The requested health service/treatment of Inpatient Mental Health is medically necessary for this patient. The patient's presentation and clinical features included severe symptoms of a mood disorder, suicidal risk, psychosis (hallucinations), and deterioration in functioning in the context of multiple comorbid conditions and a potentially lethal suicide attempt immediately prior to her admission. The patient remained at risk for relapse during the time interval under review thru discharge. A safe and clinically appropriate discharge plan and disposition was critical in this case to prevent re-hospitalization or immediate relapse or a suicide attempt, especially with regard to the family conflict/tension in the case which was a major perpetuating factor. The patient could not have been expected to participate in treatment at a lower level of care during the time interval under review. Additionally, the inpatient stay was medically necessary in order to monitor the response to therapeutic interventions, to insure that the patient will have a sustained response to treatment, and to continue to address the acute risk of suicidal behavior in the context of severe symptoms of a mood disorder and severe psychosocial stressors in a patient with impaired judgment and poor control of impulses.