Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Anxiety and depression
Issue under review: Continued inpatient admission

Determination:
The Continued inpatient admission was medically necessary.

The patient is an adult male with a history of mental illness who received inpatient psychiatric care.

The patient has a history of mental illness and has been diagnosed with schizoaffective disorder.  He has a history of prior inpatient psychiatric hospitalizations as well as substance abuse.  There is a history of alcohol and cannabis abuse.  There is a history of non-compliance with psychiatric treatment as well as aggression.  

The patient's grandmother activated emergency services due to concerns of aggressive and disruptive behaviors.  The patient was brought to the emergency room for evaluation and reported symptoms of anxiety and depression.  He was noted to be responding to internal stimuli and abusing alcohol and cannabis.  Angry outbursts were noted.

The patient was medically cleared for psychiatric hospitalization and was admitted.  He was treated by a multidisciplinary team including psychiatry, nursing, and therapy staff.  He received individual and group therapy.  He received a psychopharmacology evaluation and was started on Depakote, Risperidone, and Cogentin.  

A week after admission, the patient was noted to have ongoing psychiatric symptoms including poverty of speech and internal preoccupation with depression and anxiety.  

The following day, the patient was noted to have internal preoccupation as well as being guarded and isolated.  

Two days later, the patient was discharged to outpatient psychiatric follow up.

The patient represented an acutely elevated risk of dangerous behaviors, and there was no less-restrictive treatment environment appropriate.  The acute risk factors of psychosis with the chronic risk factors of potentially dangerous behaviors suggest that the patient would have been at an acute risk of aggressive or self-injurious behaviors (including but not limited to suicide) were he to have been discharged from the inpatient hospital setting.  The patient was discharged from the inpatient psychiatric hospital setting as soon as a less-restrictive treatment setting was appropriate.  

The patient represented an elevated risk of dangerous behaviors, including aggressive behaviors, self-injury, and suicide, and there was no less-restrictive treatment environment appropriate.  Therefore, the treatment was medically necessary.  While the patient was not endorsing active suicidality or homicidality, the patient remained psychotic with depression and anxiety.  The patient had multiple static risk factors for potentially dangerous behaviors including history of aggressive behaviors and diagnosis with a severe mental illness.  Therefore, the patient represented a chronic risk of potentially dangerous behaviors.  The fact that the patient remained psychotic was acute risk factor for dangerous behaviors.  Furthermore, the fact that there was no less-restrictive environment of care appropriate suggests that ongoing inpatient psychiatric hospitalization was medically necessary and should be covered by the patient's health plan.