Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Major Depressive Disorder, Suicidal Behavior
Treatment: Inpatient Mental Health Stay
The insurer denied the Inpatient Mental Health Stay.
The determination is upheld.

The patient was admitted to acute inpatient psychiatric services for treatment of recurrent and severe major depressive disorder associated with acute suicidal behavior and an attempt to commit suicide by cutting his wrists. The patient was evaluated at the time of presentation and was subsequently admitted and was treated with inpatient mental health/psychiatric services. There were no substance use disorders in this case, other than past use of alcohol and "edibles;" a drug screen was negative and consistent with his history. He was medically screened in the emergency department and cleared for admission to acute inpatient mental health services.
The patient has a history of a mood disorder treated with Paxil and Wellbutrin. He was receiving outpatient treatment with therapy/counseling. There was a history of one prior psychiatric hospitalization. He had no substance use disorder diagnoses, and no general medical issues other than pre-diabetes and the laceration of his wrist.
The patient is married, college educated, employed and lives with his wife and two daughters. There is a family history of depression and completed suicide reflecting genetic predisposition.
Mental status examination on admission included mood that was depressed with anxiety. He was cooperative with good eye contact and clear speech that was soft. There was no evidence for psychosis, thought disorder, severe cognitive impairment, or perceptual disturbance. There were no somatic concerns other than sleep disturbance. Insight and judgment were fair and poor, respectively and the patient had anhedonia, hopelessness and low self-worth with depressive ruminations.
The patient was admitted to the acute inpatient psychiatric level of care with a diagnosis of major depressive disorder. He was continued on his psychotropic medications, titrated as clinically appropriate with adjustments. He had the opportunity to participate in individual and group therapy, group activities, and participate in other milieu interventions. He actively attended groups and other milieu activities. The patient's mood had improved with diminished anxiety and better sleep addressed with low-dose quetiapine and melatonin. He continued to deny suicidal ideation and was feeling better. The patient was maintained on the psychotropic regimen that included Wellbutrin, Paxil, and the addition of Abilify for augmentation with adherence and tolerability.
The treatment team and attending physician were discharge planning in concert with the patient's spouse who was reluctant to have the patient home. The patient received continued inpatient treatment. During this time interval, records indicate that the patient's mood was "fine" with congruent affect and denial of suicidal thoughts. He was future focused and remorseful for his suicide attempt, and his judgment was considered good. A discharge plan was developed in concert with the patient's spouse with immediate transfer for residential level services and a safety plan.
Throughout the hospital course the patient had not exhibited severe psychiatric symptoms including psychosis, severe cognitive impairment, mania, or thought disorder; he had not shown active suicidal ideation or aggressive impulses or violent intent. Discharge medications included Paxil 40 milligrams (mg), Wellbutrin 300 mg and Abilify 2 mg.
The health plan documents were reviewed including case notes and level of care guidelines/medical necessity criteria, as well as correspondence from the health plan and the treatment facility, and the patient's appeal documents. The dates under review were denied certification by the health plan for continued acute adult inpatient level psychiatric treatment on the basis of medical necessity indicating that the patient could have been safely managed with lower-level care such as partial hospital program treatment. This is a New York State mandated review.
At issue is the medical necessity of continued Inpatient Mental Health Treatment.
The requested health service/treatment of inpatient mental health treatment is not medically necessary for this patient.
The intensive treatment for the depressive disorder including safety monitoring did not require the continued structure of an acute inpatient level of care or 24-hour monitoring. The patient did not display continued evidence of a suicidal ideation, plan or intent, and did not engage in self-harm during the hospital course; other symptoms such as severe cognitive impairment (dementia or delirium), thought disorder, mania or psychosis were not present in this case, nor was there psychiatric co-morbidity or co-occurring substance use disorders that would have warranted the continued acute inpatient level care. The patient was generally cooperative with treatment and he was medication adherent with tolerability and engaged in treatment with family support.
The psychosocial stressors in this case were not so severe to require continued acute inpatient care or 24-hour monitoring during the time interval under review in this case. Additionally, the patient had access to services in the community with the availability of continued treatment for his mood disorder.
Medical necessity for continued acute inpatient level care is not met in this case for the time interval under review. These answers are consistent with published practice guidelines, the scientific literature as well as prevailing standards of medical practice.