Appeal type: Medical necessity
Decision: Upheld

The patient is a male who was admitted to acute inpatient mental health treatment for worsening symptoms of a psychotic disorder in the context of having been discontinued from his antipsychotic medications. His presentation for services was in the context of severe stress in that his primary caregiver, his grandmother, presented at the same time with a cerebrovascular accident (stroke) with no certainty whether she would survive. The patient was noted to have bizarre behavior and he exhibited delusional thinking with paranoid thought content that resulted in severe symptoms of anxiety and agitation. His delusions included thoughts of being the devil and in Hell, and he was acutely agitated and yelling at devils, and religiously preoccupied. 

The patient was admitted to inpatient psychiatry with a comprehensive evaluation and development of a treatment plan. Upon initial evaluation, there were no general medical issues in this case, and the drug screen and other laboratory assessments were negative and normal, respectively other than the vitamin D deficiency, as noted. The patient received monitoring, medications targeting symptoms of psychosis, and he had the opportunity to participate in group, educational, and milieu therapies.

The patient was participating in therapy with reasonable attendance at groups and interaction with peers. There had been no episodes of acute agitation requiring prn medication; discharge planning had occurred with disposition planned to include placement with the respite bed with outpatient follow-up and other services. The patient was discharged with a diagnosis of schizophreniform disorder and rule out schizophrenia and autism with clinically appropriate mental health aftercare to include medications, risperidone 3 milligrams (mg) at bedtime, Abilify 5 mg in the morning and Cogentin 1 mg daily.

The health plan's determination is upheld, in whole. 

The acute inpatient mental health stay and treatment is not medically necessary for this patient. The patient no longer required the structure or the 24-hour monitoring of an acute inpatient level of care in order to administer continued treatment for the psychiatric disturbance including support of daily activities and safety monitoring.

It was not medically necessary for this patient to have acute inpatient level services in view of his improved functioning and lack of risk for erratic or impulsive behaviors, as well as improved insight and cooperation with staff with regard to daily functioning. There were no general medical issues or co-occurring substance use disorder complicating this case that would have required the continued acute inpatient level services. Additionally, the inpatient stay during this time interval 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 management, as the patient's acute symptoms of psychosis had resolved or remitted. The patient had access to continued mental health treatment in the community and the continued stay was primarily focused on placement and housing. Moreover, the patient was attending off site services and subsequently resumed participation in his college classes. Thus, mental health treatment could have continued in a less restrictive setting and medical necessity is not met in this case for the time interval under review.