Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Major Depressive Disorder.
Treatment: Mental health inpatient admission.
The insurer denied coverage for the mental health inpatient admission.
The denial is overturned. 
	   
This is male patient who was admitted to inpatient mental health treatment after going to the Emergency Department (ED) the day before.  He reportedly presented with severe depressive symptoms including depressed mood, 35 pounds (lbs.) of weight loss in one month, poor sleep, hopelessness, anhedonia, poor functioning, and suspicion of non-compliance with medication.  He reportedly had eight panic attacks in one week along with anxiety.  It was reported that he could not handle his worsened depression and anxiety.  He was in outpatient Psychiatric treatment and had worsened depressive symptoms and poor functioning.  He had a reported history of a past psychiatric hospitalization and three prior inpatient rehabilitation treatments.  He reportedly had diagnoses of Major Depressive Disorder, Panic Disorder, and Generalized Anxiety Disorder.  He reportedly took Paxil and was discharged on day 3 of admission.

The Milliman Care Guidelines (MCG) Behavioral Health Inpatient Level of Care Adult-Geriatric criteria reports that patients who present as an imminent danger to self, imminent danger to others, with severe psychiatric or behavioral symptoms, have severely dysfunctional living including inability to care for self, unwillingness to participate voluntarily, or a less restrictive level of care is not feasible, meet criteria for inpatient behavioral health level of care.  

The InterQual  Behavioral Health Adult and Geriatric Psychiatry Inpatient medical necessity criteria reports that if one has assaultive behavior within 24 hours, catatonia, command hallucinations to harm self or others, destruction of property with poor impulse control within 24 hours, disorganized behavior, unstable eating disorder, fire setting, homicidal or suicidal attempt within 24 hours, suicidal or  homicidal ideation with high risk for an attempt, mania, risk of harm to self or others, non-suicidal self-injury and continued danger to self, positive psychotic symptoms with risk of harm to self or others, posttraumatic stress disorder (PTSD) with risk of harm to self or others, psychomotor agitation and potential for violence, severe social withdrawal and refusing treatment, unavailable support or inability to provide needed care and supervision and there is acute deterioration in functioning then criteria is met for inpatient treatment.  

This patient had an acute deterioration in functioning.  He had severe depressive symptoms in addition to difficulty functioning and significant weight loss.  He was noted to be overwhelmed and had recent stressors.  He had past psychiatric hospitalization and past alcohol and cocaine use so he was considered in need of 24 hour hospital treatment due to severe depressive symptoms and poor functioning with a weight loss of 35lbs. in one month.  He reportedly was in outpatient psychiatric treatment and his depressive symptoms were worsening.  

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 inability to adequately care for basic needs are candidates for hospitalization. This patient reportedly had significant weight loss in one month so that was specific evidence that he had inability to care of his needs and also had severe depressive symptoms also reported including depressed mood and feelings of hopelessness.  

It did not appear that the health care plan acted reasonably or in the best interests of the patient then.  

The carrier's denial of coverage for the mental health inpatient admission is overturned.  The medical necessity is substantiated.