Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Suicide attempt. 
Treatment: Inpatient Hospital Stay. 

The insurer denied the inpatient hospital stay. 
The determination is overturned. 

The patient has a history of depression and anxiety treated with Lamictal and Lexapro who was transferred to the accepting emergency room (ER) from an outside hospital after intentional ingestion of 11 times (x) 10 milligram (mg) Lexapro tablets and 12 x 25mg Lamictal tablets along with a beer. About 1.5 hours later she woke up vomiting and texted her friend who then called the police. She reported suicidal ideation but reports she regrets the decision on presentation. 

Labs done at the outside hospital were significant for a normal complete blood count (CBC), normal electrolytes, normal liver function tests (LFTs), negative Tylenol, salicylate and ethanol level. Poison control was contacted who recommended 24 hours of cardiac monitoring. The patient was transferred for further care. She was monitored in the emergency department (ED) for 24 hours after the ingestion for cardiac instability and remained stable. She was evaluated by psychiatry who recommended inpatient admission. In the ER, basic labs were normal except for mild anemia, urine toxicology (U Tox) was negative. 

A urine human chorionic gonadotropin (HCG) was negative and coronovirus (COVID) was negative. Her urinalysis (UA) was indicative of an infection and a urine culture grew gram negative bacilli greater than (>) 100 thousand (K) colony forming units (CFU) so she was started on Macrobid. She denied any UTI symptoms or history of UTI infection.  She vapes one cartridge a day of nicotine. She occasionally drinks alcohol and reports that she drank every day for a month over a year ago because she was bored. She endorses intermittent cutting of her arms with a razor blade. She denies active suicidal ideation and reports that she never intended to kill herself. She had no physical complaints. The admission assessment reported the patient was medically cleared and admitted to general pediatrics pending psychiatric placement. No inpatient psychiatric beds were available. The patient was placed under 24 hour continuous observation and continued on Macrobid for the UTI. An inpatient psychiatric bed became available. The patient was transferred out for further management and care. 

At issue is the medical necessity of an inpatient stay. 

The requested health service/treatment of inpatient stay was medically necessary for this patient. 

This patient presented to the ER after a suicide attempt in which she overdosed on her prescription medications (Lamictal and Lexapro). Given the possibility of cardiac complications and EKG changes, the patient was monitored for 24 hours in the ER and subsequently medically cleared. The psychiatrist assessed the patient and due to her suicidal behavior and attempted self injury, inpatient level of psychiatric care was recommended but no beds were immediately available. To safely care for this patient prior to the availability of an inpatient pediatric psychiatric bed, inpatient care with 1:1 observation to prevent harm to herself or others was indicated and in the best interest of the patient. The level of care needed to monitor her condition was more involved and complex than services that would be provided at a lower level of care. Constant monitoring was necessary, 24 hours a day for the recurrence of suicidal and/or aggressive behaviors. As there was no timeline for an expected discharge date or availability of beds, the patient required an inpatient level of care on the pediatric floor while awaiting safe disposition. Inpatient care is the standard for pediatric patients with active and current suicidal behaviors. Per the Milliman Care Guideline General Recovery Guidelines (GRG) Pediatric General Admission Criteria, Criteria for inpatient level of care includes severe behavioral health issues judged unmanageable at lower level of care (eg residential) in a patient who is acutely suicidal or a danger to self (eg, self-mutilating). 

For these reasons, the patient's admission was medically necessary and appropriate for an inpatient level of care.