Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Psychosis, major depressive disorder
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is overturned.

This case involves a female admitted for acute inpatient evaluation and treatment of an acute psychosis in the context of general medical and neurological comorbidity and past diagnosis of an unspecified mental disorder and behavioral disturbance which had required hospitalizations twice in the previous year. The patient was brought in by emergency medical services presenting with symptoms of psychosis characterized by auditory hallucinations and paranoia. She was found to be combative, agitated and paranoid resulting in a 911 call and transfer to the emergency department; she required Versed to address the agitation during her transfer.

A comprehensive evaluation was conducted/completed with testing that had included laboratory assessments, computed tomography (CT) scan of the head, electrocardiogram (EKG) and physical examination. Results were normal or unremarkable as the evaluation was completed in the emergency department. She had a history of hypertension and hypothyroidism with associated treatments, as well as a hospitalization last Winter for a hypertensive crisis and small aortic aneurysm, as well as carotid stenosis.

The patient has a recent history of behavioral disturbance, as noted, with a hospitalization.

The mental status examination included dysphoric mood and constricted affect with motor agitation and underproductive thought that included content suggesting paranoid ideation. She had evidence for auditory hallucinations, as well as the mood disturbance with morbid thoughts and diminished energy and volition. Her insight was limited and judgment impaired with inability to care for self. She was notably agitated due to her morbid thought content and attention to internal stimuli, mumbling coherently. She had decreased appetite, concentration, energy, sleep and volition with poor attention and concentration.

The patient was admitted to acute inpatient level services with close observation, safety monitoring, and psychiatric consultation as well as continued neurologic work up to identify an underlying cause for her neuropsychiatric disturbance. While conducting an evaluation for an underlying medical condition, risperidone was prescribed and the patient accepted the medication. The patient continued to display signs of psychosis and was responding to internal stimuli. She was agitated and running up and down the hall of the hospital requiring staff intervention and continuous observation. She was considered at risk for aggressive or erratic behavior. An electroencephalography (EEG) and magnetic resonance image (MRI) of the head was recommended and resulted in a finding of a lacunar infarct thought to be old. Otherwise, no other neurologic disease was identified. Psychiatric consultation diagnosed the patient with an unspecified psychosis and major depressive disorder.

The patient seemed less preoccupied with her auditory hallucinations and was improved with respect to thought processing, mood and functioning. Sleep and appetite were okay. Case management was considering a safe and clinically appropriate disposition in concert with the patient's daughter. The patient was continued on her general medical medications including antihypertensive medications, cholesterol medication and thyroid replacement as well as low-dose aspirin. She was tolerant of her medications including risperidone 0.5 milligrams (mg) twice daily. Overall, the patient was more spontaneous with improved mood and diminished anxiety. She had consistently denied suicidal ideation or aggressive impulses. Her family/daughter supported the discharge plan to return to the community with mental health and general medical follow up.

The reason for denial was that medical necessity not met with the application of the plan definition and Milliman Care Guidelines (MCG) level of care guidelines pertaining to "Neurology".   An appeal from the treatment facility indicates that the inpatient admission and stay was medical necessity due to safety concerns and the patient's behavioral disturbance in the context of limited insight, impaired judgement and poor impulse control, and the need to provide a clinically appropriate evaluation with a safe and clinically appropriate disposition and aftercare plan.

Yes, as the treatment facility asserts with an appeal, the proposed treatment was medically necessary for this patient.
The patient required the admission and the continued acute inpatient level care and the structure and monitoring of an acute inpatient level setting in order to remain safe and to administer treatment for her psychiatric disturbance with severe depression and psychotic features or an unspecified psychosis with underlying general medical and neurologic conditions. The admission was warranted in order to conduct an evaluation and observe her functioning with the resumption/adjustment of clinically appropriate medications. The clinical course was complicated by the presence of psychosis and functional impairment being addressed during the time interval under review. Additionally, the treatment team was planning for a safe and clinically appropriate disposition with aftercare arrangements in concert with the patient's family and with community providers.

The medical necessity for the admission and the continued inpatient level structure and monitoring is reasonable, and in the patient's best interest in view of the patient's severe symptoms of mood disturbance, psychosis, and co-morbid medical conditions. And, in view of these clinical features and the complicated presentation with psychosis and deterioration in functioning, the patient's continued active treatment with safety monitoring was warranted in the context of the patient's deteriorated functioning and risk for medical comorbidity. Additionally, the inpatient stay was medically necessary in order to monitor the response to medication, to ensure that the patient would have a sustained response to treatment, and to continue to address the acute risk of relapse or non-compliance or rehospitalization in the context of severe symptoms of a mood disorder in a patient with impaired judgment and a limited insight and deteriorated functioning. The necessity for the admission and continued inpatient level services is in keeping with prevailing standards of professional practice, and with the published practice guidelines, referenced below, as well as New York State instruction for this medical necessity review.

The patient's presentation and clinical features included severe symptoms of mood disorder, psychosis and deterioration in functioning with inability to care for self in the context of multiple comorbid conditions. The patient remained at risk for relapse during the time interval under review thru discharge. Additionally, a safe and clinically appropriate discharge plan and disposition was critical in this case to prevent re-hospitalization or immediate relapse or complications related to the neurologic and general medical conditions. The patient could not have been expected to participate in treatment at a lower level of care during the time interval under review- in this case scenario.