Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Anxiety, Depression, Substance use 

Treatment: Inpatient Mental Health Services

The insurer denied coverage for the Inpatient Mental Health Services.

The denial is upheld.

This is a male patient with a history of asthma, substance use issues, anxiety, depression, trauma, and attention deficit hyperactivity disorder (ADHD) who was admitted for inpatient mental treatment due to trauma issues. The patient's substance use included using 5 bars of Xanax per day, and binge drinking alcohol 5-10 drinks. The patient also had a past history of opiate use including using oxycodone daily. The patient reported that he had past charges for possession. The patient reported having mood swings and depressive symptoms, and was buying medication off the street to treat his depression. The patient reported that he was experiencing more aggression, difficulty getting out of bed, tearful, insomnia, and lack of motivation. 

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. Also, the APA Practice Guidelines for the Treatment of Patients with Acute Stress Disorder (ASD) and Posttraumatic Stress Disorder (PTSD) reports that for the majority of individuals with ASD or PTSD, treatment on an outpatient basis is the most appropriate treatment setting. However, patients who exhibit suicidal or homicidal ideation, plans, or intent require close assessment and monitoring and inpatient treatment is generally indicated for patients who are considered to pose a serious threat of harm to themselves or others. 

In this case, this patient did not have reports of being a danger to self or others. The patient had reports of trauma issues as well as substance use issues and mood symptoms but there was no specific evidence in the patient's medical records to support that this patient could not be treated in a less restrictive level of treatment. Also there were no reports that the patient failed a less restrictive level of care, such as a partial hospital program treatment prior to requiring inpatient level of care. Also, there were no specific identifiable or quantifiable treatment goals or objectives that could only be achieved in a 24-hour mental health inpatient treatment or that could not be achieved in a less restrictive setting. There were no reports of suicidal or homicidal ideation, plan, intent, or attempts, psychotic symptoms, manic episodes, severe depressive episodes, self-injurious behavior, and/or aggressive, threatening, or out-of-control behavior, medical instability. The patient did not present with severe withdrawal symptoms or any specific evidence that he was considered an imminent danger to self or to others. Thus, based on the review of the medical record and literature, inpatient mental health services were not medically necessary for this patient.

The health plan acted reasonably with sound medical judgment and in the best interest of the patient.

The medical necessity for the Inpatient Mental Health Services is not substantiated. The insurer's denial should be upheld.