Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Poly-substance induced mood disorder.
Treatment: Inpatient mental health services.
The insurer denied the inpatient mental health services.
The denial is overturned. 

The case involves a male who was admitted to inpatient mental health treatment. The patient was found unresponsive by a family member with an apparent drug overdose. He was seizing and turning blue. Emergency services were called, administered Narcan, and brought the patient to the emergency department for services. The patient was alert and oriented following his arrival. He indicated that he was sad and using multiple substances of abuse with heroin and methamphetamine as drugs of choice and the drugs that resulted in the accidental overdose. He also had intermittent use of mollies, prescription narcotics, and tobacco with use of one pack per day. He admitted to also using alcohol socially and occasionally misusing Xanax. Thus, the patient was diagnosed with a poly-substance use disorder with opioids (heroin and prescription narcotics), stimulants (methamphetamine and mollies) and cannabis (marijuana) as the drugs of choice using these substances of abuse in large quantity. The patient was diagnosed with a co-occurring psychiatric disorder best characterized as substance induced mood disorder. The patient's substance use started in adolescence with escalating use in the context of high-risk behaviors and the mood disturbance.

The patient was medically screened with laboratory assessments, electrocardiogram (EKG) and chest x-ray which were normal or unremarkable. He was stabilized in the emergency department and admitted for inpatient mental health treatment. He was placed on safety checks and had the opportunity to participate in group and other therapies focusing on coping skills while maintaining abstinence from substances of abuse with monitoring. He was prescribed psychotropic medications, Effexor with use of clonidine and hydroxyzine for agitation and anxiety, and medication assisted treatment with Suboxone at clinically appropriate dosages and adjustments. He also received nicotine replacement.

Progress notes and documentation indicate that the patient engaged with treatment with persistent symptoms of anxiety and depression, but no suicidal ideation or aggressive impulses. The patient was noted to have improved with some degree of self-awareness and better insight, though he was deemed to be at high risk for relapse. And, the patient was working on an exit strategy with plans for discharge with referrals to community services and clinically appropriate aftercare, and continued medication assisted treatment with Suboxone and mental health treatments including the use of Effexor. He was successfully discharged with outpatient follow up.

The denial determination was on the basis of medical necessity and InterQual Criteria indicating that there were no safety concerns in this case and that the treatment could have been provided with lower-level care in a less restrictive treatment setting.

The treatment facility appealed on the basis of safety concerns with severe substance use and high-risk presentation and behaviors together with the mood disturbance and need for a safe and clinically appropriate discharge and disposition in keeping with standards of medical practice.

The issue under review is inpatient mental health services.

Yes, the proposed treatment, inpatient mental health stay, was medically necessary.
Inpatient mental health stay was warranted by the patient as well as continued structure and monitoring of the inpatient level services that were provided together with ongoing efforts to treat the mood disturbance and to address the patient's risk of relapse while the treatment team and patient worked toward a clinically appropriate disposition with continued mental health services to address the co-occurring mood disorder and poly-substance use disorder including the initiation of medication assisted treatment with Suboxone. 

The patient had a history of continuous use of substances in large quantities, and lacked the insight and control of impulses to remain sober and remain engaged in treatment during the time frame under review. The treatment team was working on motivation for the patient to remain abstinent and addressing mood and affect disturbances in the context of symptoms of the mental disorder that complicated the case. The patient's lack of awareness or limitations of insight and impulse control was a significant clinical feature of the patient's history, together with the seriousness of the substance use disorder with use of multiple substances of abuse with high risk for another overdose or impulsive behavior due to paranoia. These factors support the assertion that the patient could not have been effectively treated at a lower level of care until which time the patient was more stable with better self-awareness such that he was better able to continue working on the remaining psychological issues and development of better coping skills and motivation to remain in a recovery process with a solid relapse prevention plan.

No, the health plan did not act reasonably, with sound medical judgment and in the best interest of the patient.
The requested inpatient mental health treatment was warranted and in keeping with prevailing standards of medical practice and consistent with the published guidelines and scientific literature, referenced below, including New York State instruction for this review and application of New York State Office of Alcoholism and Substance Abuse Services (OASAS) Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) Criteria.