Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis:  Schizoaffective disorder.
Treatment:  Inpatient Mental health stay.

The insurer denied the inpatient mental health stay.  The health plan's determination is overturned in part.  36 days of inpatient mental health treatment was medically necessary. 

The patient is a woman with diagnoses of schizoaffective disorder, bipolar type, who was admitted to inpatient psychiatry after medical evaluation and stabilization.  She had additional diagnoses of morbid obesity and diabetes mellitus.  Case notes document that on admission, the patient was severely ill, malodorous with swollen legs and sores, showing poor activities of daily living.  She had clearly been unable to maintain proper hygiene.  She had not been able to adhere to her medications (risperidone and Depakote) for several months.  She previously failed several trials of anti-psychotic medication.  She had consistently refused Clozaril.  She showed thought blocking, grandiose delusions, and a labile mood.  She had poor judgment and poor impulse control.  She was initially treated with dual anti-psychotics of paliperidone and Haldol plus Depakote, but then the regimen was simplified to Haldol and Depakote alone.  She received psychoeducation, behavioral management, and group treatment.  A good plan for follow-up with ACT was made.  High stressors included homelessness and inability to function in a job.  She had little support.  She showed severe functional impairment.  

36 days of inpatient mental health treatment was medically necessary.  For this patient with severe chronic illness and medical comorbidities and high functional impairment and multiple psychosocial stresses, there is no simple single datum or finding to support discharge.  Rather, a cluster of symptoms and signs of improvement in what appeared to be a stable baseline is a reasonable standard.  This patient had to be treated for both her psychotic and mood symptoms.  Complex psychopharmacology is required in treatment of schizoaffective disorder. Patients with schizoaffective disorder may require trials with different antipsychotic medications.  

On the proposed day of discharge by the health plan, the patient showed a brief pause in her symptomatology with some logical conversation and good appetite.  However, she did not remember refusing medications, setting herself up for relapse.  For this patient to be safely discharged with good medical judgment, a period of several days of baseline mental status and non-threatening behavior are necessary for several reasons.  A single day of moderate improvement was not enough.  She was at high risk if discharged because her disorder was chronic and severe with high functional impairment, and she lacked evidence of consistent improvement adequate for movement to a lower level of care.  She had been non-adherent to her medications for months.  She was homeless.  She had no significant dependable support.  She had severe medical comorbidities.  The case notes document that the patient waxed and waned in her symptoms as her medications were increased, primarily the paliperidone, along with psychoeducation, and behavioral teaching about the need for adequate hygiene.  She had a labile mood and was agitated.  Her hygiene continued to be poor.  She had become malodorous again with poor self-care and was responding to internal stimuli.  She was sad and depressed, illogical in thinking and continued to have grandiose delusions and required directions to shower.  She had no abnormal psychomotor activity, but her mood was dysphoric.  She had grandiose delusions.  Eventually she was calm in affect, with a stable but mildly dysphoric mood.  She had no delusions or hallucinations, no suicidality or homicidality.  The same mental status exam was noted with case notes documenting what appeared to be a baseline by day 36 of inpatient status.  She was noted to be slowly but progressively stabilizing.  Unfortunately, no approval was achieved for a long-acting injectable anti-psychotic (LAI).