Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Depression; Anxiety. 
Treatment: Inpatient hospital admission. 

The insurer denied coverage for the acute inpatient hospitalization (behavioral health). 

The denial is upheld. 

This female patient was admitted to this inpatient mental health hospital treatment due to mood symptoms including sad and irritable mood, emotional dysregulation, trauma issues, feelings of guilt, shame, and decreased self-esteem, decreased energy, anhedonia, difficulty concentrating, avoidance symptoms, worrying, fearful thoughts, panic attacks, self-isolating, somatic symptoms, issues with activities of daily living (ADLs), interpersonal difficulties, and mood changes.  She reportedly had diagnoses of Major Depressive Disorder, Generalized Anxiety Disorder, Posttraumatic Stress Disorder (PTSD), and Borderline Personality Disorder.  It was reported that her outpatient provider recommended inpatient residential treatment for more supervision and structure.  She was taking Paroxetine, Klonopin, Gabapentin, Propranolol, and Trazodone.  It was reported that she was not attending group therapy but was attending individual therapy. 

The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Major Depressive Disorders reports that the least restrictive level of care for safe and effective treatment is appropriate and that patients with suicidal plan or intent or behaviors, severe depressive symptoms, or inability to adequately care for basic needs are candidates for hospitalization. 

The InterQual Behavioral Health-Adult and Geriatric 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, 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.  Also, if symptoms improved but the patient was not clinically stable for discharge or was a high risk for re-hospitalization or a high risk of harm to self or others then criteria would have still been met. 

Based on the insurer case notes there were no reports of suicidal ideation, plan, or intent, severe depressive symptoms with inability to care for basic needs, aggressive or self-injurious behavior, psychotic symptoms, substance use problems or substance withdrawal, acute medical instability, homicidal ideation, intent, or plan, manic episodes, psychotic symptoms, self-injurious, aggressive, threatening, or agitated behavior.  She had reports of anxiety and mood symptoms including ruminating, irritable and labile mood, feeling overwhelmed, but the notes did not provide enough specific evidence that she was an imminent danger to self or others or unable to adequately care for her basic needs.  Also, there were no reports of specific identifiable or quantifiable treatment goals or objectives that could only be achieved in a 24 hour acute psychiatric hospital setting or that could not be achieved in a less restrictive setting. 

It appeared that the health care plan acted reasonably and with sound medical judgment and in the best interest of the patient. 

The insurer's denial of coverage for the acute inpatient hospitalization (behavioral health) is upheld.  Medical necessity is not substantiated.