Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Depression, Anxiety, Attention deficit hyperactivity disorder
Treatment: Continued inpatient mental health treatment 
The insurer denied continued inpatient mental health treatment. 
The denial is Upheld

This was the eighth psychiatric inpatient admission for this female with a history of depression, anxiety, ADHD, questionable exposure to trauma, and recent self-injury, who was admitted after having made a suicide attempt by overdose of lamotrigine. The patient also has history of purging and self-cutting. In addition to her multiple inpatient stays, the patient had completed three partial hospitalization programs.

She reported that in the week prior to admission she had been feeling more depressed with more frequent and persistent thoughts of suicide in the context of continued relational problems with family and peers. She reported a sexual assault a week prior to admission, which she described as being minimized or dismissed by family. She was concerned that there was "no case" as per law enforcement. 

After an altercation with her father she took an excessive dose of the lamotrigine and then sent a message to her ex-boyfriend who told her grandmother. At the urging of her ex-boyfriend she agreed to call 911 and went to a different facility for an evaluation. She was released, but the following day she complained of stomach pains and lightheadedness and again called 911 and was taken to yet another hospital for medical evaluation but was discharged without any intervention. She spoke to her outpatient therapist who encouraged her grandmother to bring her to the hospital.

The patient had been seeing a nurse practitioner and a therapist as an outpatient. Past medication trials include aripiprazole, Vyvanse, vortioxetine, clonidine, Adderall, and lamotrigine. 

The patient was treated with individual therapy, group therapy, and pharmacotherapy. Her inpatient medications included aripiprazole,  20 mg daily, clonidine, 0.1 mg at bedtime, Vyvanse, 30 mg daily, vortioxetine, 10 mg daily, and hydroxyzine 25 mg, three times daily as needed for anxiety. 

The patient expressed passive suicidal ideation and thoughts of self-injurious behavior throughout her stay. She was, however, future oriented, expressing her desire to go home or to a partial hospital, while at the same time stating that she would likely not feel safe at home as there were continuing stressors.

This patient has a long history of para suicidal statements and behaviors. The precipitating event, a self-reported overdose several days earlier, did not require medical attention, and was immediately reported to others by the patient. This would not indicate lethal intent or true imminent suicidality. While this patient presented a chronic risk of self-harm, there is no historic evidence of true suicidality, and the patient's statements regarding suicidality were often made in the context of a euthymic mood and future orientation. The documentation reviewed does not support continued need for an acute level of inpatient care. Generally accepted standards for patients with similar pathology include acute inpatient stays limited to brief periods when there is clear and imminent danger of potential harm to self or others. At no time beyond the date of service in question did this patient provide evidence of credible, serious, imminent danger to self or others.