Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Attention deficit hyperactivity disorder, aggressive behavior.
Treatment: Inpatient hospital admission.
The insurer denied the inpatient hospital admission.
The denial is upheld.

The patient is a male. He was admitted to a pediatric acute inpatient level of care awaiting transfer to an acute inpatient child and adolescent psychiatric unit. He was reported to have been diagnosed with disruptive mood dysregulation disorder, attention deficit hyperactivity disorder, predominantly hyperactive type, and oppositional defiant disorder. Other diagnoses indicated include aggressive behavior, traumatic brain injury with delayed recovery and furuncle on right lower extremity. The patient was reported to have been admitted for worsening symptoms of agitation and aggression in the context of significant psychosocial stressors and conflicts with caregivers. The patient was noted to have been brought to the emergency room after he was noted to have set fire to a garbage can in the apartment hallway and locked himself in the bathroom. He was noted to have been physically aggressive towards the social worker and his mother.

The patient was reported to have a significant history of psychiatric treatment including multiple psychiatric hospitalizations in the past. He was noted to have a history of making multiple threats to harm himself in the past. There was no indication the patient had any significant history of significant physical, emotional or sexual trauma. The patient was not reported to have significant ongoing medical conditions that required hospital-based interventions or monitoring. He was reported to have a history of traumatic brain injury, status post craniotomy for subarachnoid hemorrhage sustained during a motor vehicle accident. The patient was reported to have been required to wear a cervical collar. There was no indication that the patient had any significant history of substance abuse.

The patient was provided with behavioral interventions in addition to medication management while on the inpatient unit. He was noted to have been prescribed psychotropic medications, including methylphenidate and quetiapine. Medications were noted to have been optimized for adequate symptom control. The patient was not reported to have any significant adverse effects from his psychotropic medications.

There was no indication that the patient had any significant acute behavioral symptoms. He was not reported to have any active suicidal or homicidal ideations with plans or stated intent. The patient was noted to have denied any thoughts of harming himself or others. Psychiatric progress notes consistently indicated that the patient displayed no acute psychiatric symptoms. He was not reported to have any symptoms suggestive of psychosis including command hallucinations, persecutory delusions or extreme paranoia. The patient was reported to have intermittent episodes of irritability, agitation and mood dysphoria, which appeared to be his baseline and did not represent a significant change. There was no indication that the patient had exhibited severe agitation or physical aggression while on the inpatient unit. He was not reported to have any ongoing symptoms suggestive of mania or hypomania.

No, the inpatient hospital admission was not medically necessary.

Based on current peer-reviewed, evidence-based medical literature, the requested service (acute inpatient stay) was not found to be medically necessary. The clinical information provided does not indicate that the service requested was the least restrictive setting that was medically necessary or likely to be successful in treating the patient's symptoms (1-8).

The patient had no significant ongoing medical problems that required ongoing hospital-based interventions or monitoring. He was not reported to have significant functional impairments including activities of daily living and self-care. The patient was not reported to have any significant deterioration or emergence of new symptoms for the rest of his stay on the inpatient unit. The patient was noted to have been transferred to an acute inpatient child and adolescent psychiatry unit. The patient may have been managed safely in a less restrictive setting and lower level of care than an acute inpatient unit. Therefore, continuing inpatient hospitalization was not found to be medically necessary.

Yes, the health plan was noted to have acted reasonably, with sound medical judgment, and in the best interest of the patient in denying coverage for continued acute inpatient hospitalization.

Clinical information provided does not indicate that the patient had any significant ongoing behavioral health symptoms that required continuing inpatient hospitalization. There was no indication that the patient continued to be at imminent risk of harm to himself or others. The patient was noted to have intermittent episodes of irritability and mood dysphoria which appeared to be his baseline and did not represent a significant change. There was no indication of the patient had any significant ongoing medical conditions that required interventions or monitoring. Clinical information provided does not indicate that the patient had any significant functional impairments including age-appropriate activities of daily living or self-care that represented a change from his baseline. The patient may have been treated safely and effectively in a less restrictive setting and lower level of care such as residential treatment. There was no indication that the patient continued to require acute inpatient hospitalization. Therefore, the health plan was noted to have acted reasonably, with sound medical judgment and in the best interest of the patient.