Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Agitation, aggression, irritability, impulsivity, perpetrating sexual abuse, depression, and suicidal ideation
Treatment: Continued Inpatient Mental Health Service
The insurer denied the continued inpatient mental health service.
The denial is upheld.

The patient is a female. She was admitted to the acute inpatient psychiatric unit. She was noted to have been diagnosed with attention deficit hyperactivity disorder (F90.9) and posttraumatic stress disorder (F4 3.10). The patient was reported to have been admitted for worsening symptoms of agitation, aggression, irritability, impulsivity, perpetrating sexual abuse, depression, and suicidal ideation with a plan to hang or stab herself in the context of significant psychosocial stressors including conflicts with family. She was also reported to have a history of self-injurious behaviors, including cutting. The patient was reported to have sexually abused a younger sibling.

The patient was reported to have a significant history of behavioral health treatment in the past including inpatient psychiatric hospitalization in the past. She was reported to have a history of self-injurious behaviors including cutting. The patient was reported to have a history of physical, emotional and sexual trauma as a child. The patient was not reported to have any significant ongoing medical conditions that required hospital-based interventions or monitoring. She was reported to have a history of substance use.

The patient was provided with individual, group, and family therapy while on the inpatient unit. She was prescribed psychotropic medications including clonidine, methylphenidate, hydroxyzine and guanfacine, in addition to medications for use as needed and ongoing medical conditions. Medications were noted to have been optimized for adequate symptom control based on the patient's clinical status. She was not reported to have any significant adverse effects from her medications.

No, the requested continued acute inpatient psychiatric hospitalization was not found to be medically necessary.

Based on current evidence-based, peer-reviewed medical literature and standards of care, the requested service (acute inpatient stay) was not found to be medically necessary. The clinical information provided does not indicate that the service requested was the least restrictive setting that was medically necessary or that would be likely to be successful in treating the patient's symptoms (1-8).

The patient was noted to be largely stable and at her baseline with no significant acute behavioral symptoms. The patient was not reported to have any active suicidal or homicidal ideations with plans or intent (per progress notes). She was not reported to have any symptoms suggestive of command hallucinations, persecutory delusions, or extreme paranoia. She was not reported to have any symptoms of mania or hypomania. She was not reported to have exhibited any significant agitation or aggression while on the inpatient unit. There was no indication that the patient had engaged in any self-injurious behaviors or continue to have urges for the same.

The patient had no significant ongoing medical problems that required hospital-based interventions or monitoring. She was not reported to have significant functional impairments including age-appropriate activities of daily living (ADLs) and self-care. The patient was not reported to have any significant adverse effects from any prescribed psychotropic medications. She was noted to have been participating in treatment and largely compliant with unit routines. There was no significant deterioration or emergence of new psychiatric symptoms during the patient's stay on the inpatient unit. The patient may have been managed safely in a less restrictive setting and lower level of care. Therefore, based on current peer-reviewed medical literature, the requested service (acute inpatient stay) was not found to be medically necessary.

Yes, the health plan did act reasonably, with sound medical judgment, and in the best interest of the patient.

Clinical information reviewed does not indicate that the patient had any significant acute behavioral health symptoms that required continuing inpatient psychiatric hospitalization. The patient was not found to be at imminent risk of harm to self or others. She was not reported to have any significant ongoing symptoms of depression, anxiety, psychosis, or mania that required continuing treatment of the inpatient level of care. The patient had no significant ongoing medical conditions that required interventions or monitoring. She was not reported to have any significant functional impairments including age-appropriate ADLs and self-care that represented a change from baseline. The patient may have been treated safely and effectively in a less restrictive setting and lower level of care. Therefore, the health plan was noted to have acted reasonably, with sound medical judgment, and in the best interest of the patient.