Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Increased suicidal ideation 

Treatment: Inpatient mental health admission

The insurer denied coverage for inpatient mental health admission. The denial is upheld. 

This patient is a male who was admitted to this inpatient mental health treatment in this hospital due to increased suicidal ideation with plan to overdose and worsened depressive symptoms, as well as increased alcohol use. He reported depressed mood with daily suicidal ideation and plan to overdose, feelings of hopelessness, low motivation and energy, inability to leave his home, and anhedonia. In addition to reports of paranoid ideation, there were reports of auditory hallucinations. He had a diagnosis of Bipolar Disorder. He was drinking 3 24-ounce beers per day. He had a past suicide attempt by overdose when he was a child. He had a past psychiatric hospitalization in for a manic episode with paranoia. He had a past alcohol rehabilitation treatment several years ago. He stopped Zyprexa and started Seroquel which was increased, and he also took Depakote. He improved and was discharged with a referral for outpatient mental health treatment and substance abuse treatment.

The insurer denied coverage for continued inpatient mental health treatment in this hospital. This reviewer agrees with the decision to deny coverage for continued inpatient mental health treatment in this hospital as the chart notes did not provide enough specific evidence to support that he required only 24-hour acute psychiatric hospital treatment then or that he could not be treated in a less restrictive level of care then. The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Bipolar Disorders reports that the least restrictive level of care for safe and effective treatment is appropriate and also that patients with aggression, homicidal or suicidal intent, plan, or behavior, psychotic symptoms, or severe agitation are candidates for inpatient hospitalization. In this case, this patient had initially presented with suicidal ideation and plan to overdose and severe depressive symptoms including depressed mood and feelings of hopelessness; however, as of a specified date he denied suicidal ideation, plan, or intent, or severe depressive symptoms.

As of a specified date, there were no reports of severe depressive symptoms, suicidal ideation, plan, or intent, paranoid delusions, hallucinations, disorganized speech or thought process, homicidal ideation, plan, or intent, or severe agitation. There were no reports of acute medical instability due to severe withdrawal requiring hospital treatment as of then. As of that specified date there were no reports of specific identifiable or quantifiable treatment objectives that could only be achieved in a 24-hour acute inpatient hospital setting or that could not be achieved in a less restrictive level of care then.

As a result, uphold the previous decision and deny coverage for continued inpatient mental health treatment in this hospital. The insurer acted reasonably and with sound medical judgment and in the best interests of the patient.

Based on the above, the medical necessity for the inpatient mental health admission is not substantiated.  The insurer's denial is upheld.