Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Depression and anxiety.
Treatment: Continued Inpatient Mental Health Treatment.
The insurer denied the Continued Inpatient Mental Health Treatment.
The denial is upheld. 

The patient is a homosexual transgendered female to male. The patient was admitted to the hospital.

The hospital records indicate that the patient was seen in the Emergency Department. The patient had been attending the hospital's Partial Hospital Program (PHP) due to suicidal ideation. The patient stated that the patient had suicidal ideation for a month, and that the patient tried to kill the patient's self two days prior, but it did not work. The patient overdosed on Melatonin. The patient has a history of suicidal ideation and multiple suicide attempts via overdose, hanging and cutting. The patient reported that the patient's first attempt was in the fifth grade. The patient also reported having been sexually assaulted a year ago by a male classmate and having been verbally abused by the patient's father. Prior to the patient's PHP (partial hospitalization program) admission the patient had been treated inpatient for a month. The patient also has a history of non-suicidal cutting, eating disorder and body dysmorphia. The patient reported that the patient's family does not support the patient's being transgender. The patient reported having constant suicidal ideation, and stated that the patient will eventually be successful in killing the patient's self. The patient had not told anyone while the patient was in the PHP (partial hospitalization program) about the patient's suicidal ideation so that the patient could just "off [the patient's self]," but the patient had sent a message about it to a friend who told the patient's parents. The patient did not want to be admitted inpatient, but stated that the patient would definitely kill the patient's self on discharge.

Discharge records indicate that the patient is diagnosed with Disruptive Mood Dysregulation Disorder. The patient felt ready for discharge and denied self-harm or suicidal thoughts. The patient was discharged to a transitional living program.

A letter of appeal states that the patient was accepted to a residential treatment program prior to this admission, but it was denied by insurance. The patient's mood worsened without this level of support, leading to a suicide attempt. The patient was again hospitalized and another attempt at securing residential placement was made. The patient was, however, no longer suited to the initial residential program due to the patient's suicide attempt. The patient was eventually accepted to another residential treatment program. Discharging the patient without the appropriate resources and supports in place would likely have resulted in decompensation, possibly leading to a suicide attempt.

No, the Continued Inpatient Mental Health Treatment was not medically necessary.

The patient did not display behavior requiring inpatient level of treatment. The patient was no longer suicidal, and the patient denied any thoughts of self-harm, homicidal ideation or psychotic symptoms. The patient did not engage in, or express ideation to engage in, any behaviors threatening the patient's or others' safety. The patient did not require intensive staffing and structure to remain safe: the patient did not require any staff escorts, holds or restraints or any PRNs (as needed) or IMs (intramuscular) medications. While the patient was noted to require monitoring for eating disorder behaviors, there was no information indicating that these behaviors were threatening the patient's health or daily functioning at this time; there were no reported concerns about the patient's weight or physical condition. The patient's medications were stable and the patient reported no side effects. The patient was able to engage in program treatment and activities, and did not need intensive staffing in order to engage in treatment. The patient used coping skills when necessary.

The patient's stay was reported to be due to the patient's needing to wait for a residential program bed to open up. There is no information provided to indicate that the patient could not have safely waited for this bed in a less restrictive environment. The patient indicated that the patient could remain safe in any environment except the patient's home. There is no evidence that the patient could not be maintained safely in an alternative placement, such as a group home or short term residential placement, while the patient waited for placement in the longer term treatment setting the patient's team has determined was necessary. There is no indication that the patient could not be safely contained in a setting less restrictive than inpatient during this time.

There is no evidence that the patient required continued inpatient care or that the patient could not be safely maintained during this time in a less restrictive setting.