Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Major Depressive Disorder.
Treatment:  Inpatient Stay.

The insurer denied the Inpatient Stay.  The determination is upheld.

The patient was admitted to the inpatient level of care due to depression, superficial cut of her right forearm and suicidal ideation.  The patient had been referred by her therapist, due to repetitive thoughts of suicidal ideation with a plan to jump off of a building.  The patient had no previous hospitalizations.  She was not on medications at the time of admission.  The only previous treatment was psychotherapy.  She was diagnosed with major depressive disorder, mood disorder, rule out (r/o) attention deficit hyperactivity disorder (ADHD).  She was labile and despondent.  She patient had labs and an absolute neutrophil count (ANC) was slightly low.  Consent was pending to switch the patient to Haldol instead of Seroquel, due to this lab value.  At issue is the medical necessity of a continued inpatient stay. 

The continued inpatient stay was not medically necessary.  The documentation did not reflect the patient had active suicidal ideation with plan, homicidal ideation with plan or command hallucinations.  There was no documentation that the patient was physically aggressive, acutely manic or sexually inappropriate.  The patient had a low ANC, but there was no indication of significant medical instabilities that required around the clock medical care.  The patient did not require emergency medications, restraints or seclusions.  The documentation did not reflect that a 24-hour therapeutic environment was medically necessary on an inpatient unit.

By day three of the inpatient stay under review the patient was tolerating Haldol well.  She was showing improvement and was less despondent.  The patient had 1:1 counseling.  Vitals signs were stable.  She was apprehensive and despondent.  Haldol was started at 2 milligrams (mg)mg at night.  There were no command hallucinations.  The patient was able to contract for safety.  The patient denied imminent suicidality or homicidality.  She was disorganized and irritable, with multiple somatic complaints or irritability, apprehension, insomnia and agitation.  She had anxiety.  She responded to Haldol the previous night and the dose was increased to 5 mg.  Zoloft was also increased to 75 mg.  

On day seven of the inpatient stay under review she had anxiety, irritability and depression.  The patient was sleeping better.  She had no psychosis and was able to contract for safety.  On day nine she had improvement and was less irritable.  There was no psychosis.  The patient was still preoccupied, apprehensive and labile.

On day nine of the inpatient stay she had some insomnia, vague somatic symptoms and irritability.  She was somewhat disorganized and apprehensive.  There was no psychosis.  The patient was able to contract for safety and denied suicidality or homicidality.  On day ten she showed improvement.  There were no adverse events.  The patient was able to contract for safety.  She patient was showing improvement with medication.  On day twelve the patient was noted to have galactorrhea.  Prolactin levels were ordered.  On day thirteen the patient showed improvement.  Haldol was discontinued due to concerns of lactation.  Zoloft was increased to 100 mg.  On day fourteen the patient was placed on Trazodone for sleep instead of Haldol.  The patient was able to fully contract for safety and discharge planning had started.  On day fifteen she showed improvement.  She was able to contract for safety.  Disorganization and irritability had subsided.  The patient was discharged to outpatient care the next day.