Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Schizophrenia
 
Treatment: Inpatient Admission

The insurer denied the Inpatient Admission. The denial was reversed.   

This is a male patient was admitted due to agitation, being uncooperative, inability to care for basic needs, and it was reported that the nursing facility was unable to care for him. He reportedly had a recent hospitalization after a serious suicide attempt by hanging in which he had asphyxiation, cardiac arrest, and hypoxic encephalopathy. He reportedly had PEG tube placement and a recent tracheostomy. He had a diagnosis of Schizophrenia. Psychiatry was consulted and recommended close observation. He continued to be followed and was transferred to the psychiatry unit as he continued to be unable to care for his basic needs and appeared to not be at baseline and had psychotic symptoms including oddly related, poor eye contact, questionable delusions and hallucinations, and poor memory. It was reported that the ACT team did not think he was at baseline as he denied past suicide attempts when he had a very serious recent suicide attempt resulting in asphyxiation, cardiac arrest, hypoxic encephalopathy, PEG tube placement, and a tracheostomy.

The APA Practice Guidelines for the Treatment of Patients with Schizophrenia reports that patients with hallucinations, delusional thinking, disorganized thinking or behavior, severe agitation, aggression, suicidal or homicidal intent or plan, or inability to adequately care for basic needs are in need of hospital treatment. Also, the APA Practice Guidelines for the Treatment of Patients with Suicidal Behaviors reports that patients with past suicide attempts are at high risk for suicide.

This patient had a recent very serious suicide attempt resulting in serious medical and psychiatric consequences including asphyxiation, cardiac arrest, hypoxic encephalopathy, PEG tube placement, and a tracheostomy so he was considered a high suicide risk.  In this case it was reported that he did not remember making a past suicide attempt and denied having a past suicide attempt. He reportedly stated that he did not need treatment. Notes reported that he was not psychiatrically cleared. He reportedly had somatic delusions, poor memory, denial of past suicide attempts, poor insight and judgment. Notes reported that the Psychiatry consultant recommended 1:1 observation. He also reportedly had abnormal generalized large amplitude movements of his extremity and facial movements also. He was treated with Valbenazine for tardive dykinesia. Notes reported that he shrugged when asked about suicide or homicide and he did not respond to further questions. 
This patient required and received active psychiatric treatment in this hospital even though he was on a medical unit as he was followed by psychiatry and was transferred to the psychiatric unit for further psychiatric hospital treatment.  He requires hospital treatment even in this medical hospital with psychiatric consultation as he continued with psychiatric symptoms requiring hospital treatment. 



Coverage for hospital treatment was medically necessary. It appeared that the health care plan acted reasonably and with sound medical judgment and in the best interests of the patient then.

Based on the above, the medical necessity for the inpatient admission is substantiated.  The insurer's denial is reversed.