Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Delusions of Persecution.
Treatment: Inpatient mental health treatment. 

The insurer denied coverage for inpatient mental health treatment. 

The denial is overturned. 

This patient was admitted to inpatient mental health hospital treatment with involuntary status due to worsened psychotic and manic symptoms. He reportedly had delusions of persecution, grandiosity, and religious delusions, internal preoccupation, disorganized thinking, agitation, lack of insight and judgment, noncompliance with medication, racing thoughts, labile affect and irritable mood, poor sleep, poor concentration, reckless decisions with money, mood changes, arguing, physical fights, and he felt unsafe. He reportedly had a diagnosis of schizoaffective disorder-Bipolar type and Alcohol Dependence. He reportedly had past psychiatric hospitalizations. He reportedly had past ACT [acceptance and commitment therapy] and AOT [assisted outpatient therapy]. He had a history of alcohol, cocaine, and cannabis use. He reportedly refused medications still and had poor insight and acute psychotic and manic symptoms, so a court hearing was done for medication over objection and he then was started on Lithium and Aripiprazole po (oral) as well as Aripiprazole IM [intramuscular]. He reportedly was discharged when he improved enough. 
  
The InterQual Behavioral Health-Adult 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, post-traumatic 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 meet criteria for inpatient treatment. In this case the chart notes did report continued severe psychiatric symptoms during the denial period including acute psychotic and manic symptoms. The Milliman Care Guidelines (MCG) Behavioral Health Inpatient Level of Care Adult criteria reports that a patient needs to present as an imminent danger to self, imminent danger to others, with severe psychiatric or behavioral symptoms, have a 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. 

This patient had severe psychiatric symptoms on admission requiring 24 hour hospital treatment including psychotic and manic symptoms including delusions of persecution, grandiosity, and religious delusions, internal preoccupation, disorganized thinking, agitation, lack of insight and judgment, noncompliance with medication, racing thoughts, labile affect and irritable mood, poor sleep, poor concentration, reckless decisions with money, mood changes, arguing, physical fights, and he felt unsafe. He refused psychotropic medications and lacked insight. He was psychiatrically hospitalized on an involuntary admission. 

He reportedly improved enough and was discharged. The medical records provided enough specific evidence that he was acutely psychotic and manic until discharged. 

It did not appear that the health care plan acted reasonably, with sound clinical judgment, or in the best interests of the patient. 

The insurer's denial of coverage for the inpatient mental health treatment is overturned. Medical Necessity is substantiated.