Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Schizophrenia.
Treatment:  Inpatient mental health hospital stay.

The insurer denied coverage for a continued inpatient mental health stay.  The denial is overturned. 

The patient is a male, who was admitted to this inpatient mental health treatment in this hospital due to physical and verbal aggression including throwing objects, disorganized and bizarre thinking and behavior, internal preoccupation, auditory hallucinations, delusional thinking, and he reportedly was using cannabis.  He reportedly had a diagnosis of schizophrenia and cannabis use disorder.  He was given intramuscular (IM) Haldol and Ativan initially and then Zyprexa and Risperidone.  He was also given Invega Sustenna.  
  
The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Schizophrenia reports that patients with hallucinations, delusional thinking, disorganized thinking or behavior, severe agitation, aggression, or inability to care for basic needs are in need of hospital treatment.  In this case he still had reports of psychotic symptoms, including delusions, hallucinations, negative symptoms, and cognitive symptoms during the denial period, and it was reported that he was a high risk for worsened symptoms if discharged prematurely.  Progress notes reported thought disorganization, very limited insight, and high risk for worsened symptoms if discharged before the long acting IM medication was established.  Notes reported that he was a high risk for full blown relapse, and it was reported that he had hallucinations, delusions, negative symptoms, and cognitive symptoms. 

The InterQual 2019 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, post-traumatic stress disorder (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 if there is acute deterioration in functioning, then the patient meets 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.  In this case, he needed another day of hospitalization, as he had reports of psychotic symptoms, and he was reported to be a high risk for worsened symptoms.  He had a second IM Invega Sustenna shot and then was discharged. 

The chart notes provided enough specific evidence to support that he required 24-hour hospital treatment during the denial period.  It did not appear that the health care plan acted reasonably, with sound clinical judgment, or in the best interests of the patient.

Based on the above, the medical necessity for inpatient mental health level of care admission is substantiated.  The insurer's denial is overturned.