Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Symptoms Of Depression.
Treatment: Inpatient Mental Health Treatment.
The insurer denied the Inpatient Mental Health Treatment. The denial is overturned.

The patient is an adult female. She was admitted for acute inpatient evaluation and treatment of an exacerbation of bipolar disorder with most recent episode of major depressive disorder, severe and recurrent with psychotic features. The patient presented with worsening symptoms of depression in context of psychosis and deteriorating function. She reported poor appetite and had sleep disturbance. Her medications had recently been changed and she had not followed up with outpatient mental health aftercare after being discharged from intensive outpatient program (IOP) one month prior to her presentation.  

A comprehensive evaluation was conducted/completed with testing that had included laboratory assessments and physical examination. The patient had a history of hypertension, dyslipidemia, coronary artery disease, COPD (chronic obstructive pulmonary disease), seizures, hypothyroidism and degenerative joint disease, as well as orthopedic procedures that had included bilateral knee replacement. Associated treatment included amlodipine, propranolol, oxcarbazepine, Keppra, Plavix, Breo Ellipta and a rescue inhaler.

The patient has a history of bipolar disorder, as noted, with most recent episodes depressed and worsening symptoms since discharge from IOP level care with psychotic features and past history of mania or hypomania. She has a remote history of prescription opioid and marijuana use, but denied current substance use. Drug screen was negative and consistent with her history.

The patient's mental status examination included depressed mood and constricted affect with motor retardation and underproductive thought. She had evidence for auditory and visual hallucinations, as well as the mood disturbance with morbid thoughts and ruminations and severe anxiety and diminished energy and volition. She presented as unkempt and disheveled. Her insight was limited and judgment impaired with inability to care for self. She denied suicidal ideation or aggressive impulses and was notably withdrawn due to her morbid thought content. She had decreased appetite, concentration, energy, sleep and volition with poor attention and concentration.

The patient is widowed and college educated with disability. She lives with her family that includes her oldest daughter and son-in-law and four children with guardianship of the two older children age ten and seven years. There were no legal issues or trauma-related issues. 

The patient was admitted to acute inpatient level services with close observation, safety monitoring, and pharmacotherapy supplemented with PRN (pro re nata-as needed) medications to enhance sleep and to address anxiety. The patient was withdrawn and socially isolated with severe symptoms of anxiety-apprehension, tension, worry, nervousness, and somatic concerns that persisted during her initial stay. She was started on Seroquel at a daily dose of 400 mg (milligrams) together with Cymbalta, Lexapro and Buspar, and had the opportunity to participate in group, individual and educational sessions, as well as family focused sessions that were addressing appropriate aftercare and need for compliance with treatment. Throughout her brief inpatient stay, the patient isolated in her room and had to be encouraged to participate in milieu activities. 

The patient's hallucinations had resolved and she reported a positive outlook with better functioning. She was medication adherent with tolerability. Thus, she was deemed to be capable of treatment with lower level care and was discharged to home with clinically appropriate aftercare and continued use of her psychotropic medications with plans for resumption of IOP care. On the day of discharge, she was more spontaneous and well-groomed with improved mood and diminished anxiety. She had consistently denied suicidal ideation or aggressive impulses. Her family supported the discharge plan and had remained supportive throughout her inpatient stay.

Yes, the Inpatient Mental Health Treatment was medically necessary for this patient.

The patient required the admission and the continued acute inpatient level care and the structure and monitoring of an acute inpatient level setting in order to remain safe and to administer treatment for her psychiatric disturbance, bipolar mood disorder with severe depression and psychotic features. The admission was warranted in order to conduct an evaluation and observe her functioning with the resumption/adjustment of clinically appropriate medications. The clinical course was complicated by the presence of psychosis and functional impairment being addressed during the time interval under review. Additionally, the treatment team was planning for a safe and clinically appropriate disposition with aftercare arrangements in concert with the patient's family with whom she lived and with community providers.

The medical necessity for the admission and the continued inpatient level structure and monitoring is reasonable, and in the patient's best interest in view of the patient's severe symptoms of mood disorder, risk for relapse, and co-morbid medical conditions. In view of these clinical features and the complicated presentation with psychosis and deterioration in functioning, the patient's continued active treatment with safety monitoring was warranted in the context of the patient's deteriorated functioning and stressors involving primary support and general medical domains. Additionally, the inpatient stay was medically necessary in order to monitor the response to medications, to insure that the patient would have a sustained response to treatment, and to continue to address the acute risk of relapse or non-compliance or rehospitalization in the context of severe symptoms of bipolar mood disorder in a patient with impaired judgment and a limited insight and deteriorated functioning. The necessity for the admission and continued inpatient level services is in keeping with prevailing standards of professional practice, and with the published practice guidelines, referenced below, as well as New York State instruction for medical necessity reviews.

The patient's presentation and clinical features included severe symptoms of mood disorder and deterioration in functioning with inability to care for self in the context of multiple comorbid conditions (general medical), and non-compliance with outpatient treatment including recent IOP level care with loss to follow up. The patient remained at risk for relapse during the time interval under review thru discharge. Additionally, a safe and clinically appropriate discharge plan and disposition was critical in this case to prevent re-hospitalization or immediate relapse or complications related to general medical conditions. The patient could not have been expected to participate in treatment at a lower level of care during the time interval under review in this case scenario.