Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Alcohol use disorder; psychosis
Treatment: Inpatient Hospital Admission
The proposed treatment, continued Inpatient hospital admission, was not medically necessary for this patient.

The continued inpatient level hospital care was not medically necessary for this patient. The patient no longer required the structure of an acute inpatient level of care in order to remain safe or to administer continued treatment for the psychiatric disturbance including support of daily activities and safety monitoring together with medication management and other therapeutic interventions. It was not medically necessary for this patient to receive continued acute inpatient level services in view of his improved mood and affect, resolution of overtly psychotic symptoms, and relative lack of impulsive behaviors, as well as improved insight and cooperation with staff with regard to daily functioning and medication adherence. There were no general medical issues or co-occurring substance use disorders complicating this case that would have required continued acute inpatient level services; the patient's alcohol use disorder did not require continued acute inpatient level treatment or 24-hour monitoring. Additionally, the inpatient stay during the time interval under review was not medically necessary in order to monitor the patient for at-risk behaviors, or to address the acute risk of relapse or address the issue in this case with medication non-adherence. The patient had access to continued mental health and substance abuse treatment in the community that could effectively meet the patient's continued mental health needs. Thus, treatment could have continued in a less restrictive setting and medical necessity is not met in this case for the time interval under review. This answer is consistent with the practice guidelines and scientific literature referenced below as well as New York State instruction for medical necessity reviews.

The patient's presentation and clinical features included an exacerbation of the patient's psychotic and mood disorder in the context of severe symptoms of psychosis, depression, and deterioration in functioning. The patient exhibited cognitive impairment (disorder thought processing and executive function) and perceptual disturbance (presence of perceptual disturbance- hallucinations) acting on his paranoid thought content with guarded behavior and medication non-adherence and substance abuse with alcohol, and a decline in functioning with limited insight. The patient responded to treatment such that by the dates in question, he had no remaining safety issues or persistent symptoms of psychosis that placed him at imminent risk for harm to self or others. There was no evidence of other symptoms or behaviors that would have required continued acute inpatient level of care, as noted above. The patient could have been managed at a lower level of care during the time frame under review. Thus, the health plan's determination is reasonable and reflects sound medical judgment. This answer is consistent with the practice guideline and scientific literature referenced below as well as New York State instruction for medical necessity reviews, and other references pertinent to the patient's co-occurring alcohol use disorder and severe and persistent mental disorder.