Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Schizophrenia

Treatment continued inpatient mental health treatment

The insurer denied coverage for continued inpatient mental health treatment

The denial is overturned

This is the case of an adult female patient who was admitted to this inpatient mental health treatment after a transfer from the neurological intensive care unit (ICU) in which she had intubation due to respiratory failure and hypercapnia and seizures. She had auditory hallucinations, internal preoccupation, agitation, aggression physically and verbally, pressured and loud speech, refusal of medications leading to uncontrolled hypertension and hypoglycemia, irritable mood, disorganized thinking and behavior, inability to care for activities of daily living (ADLs) or basic needs, threatening and disruptive behavior. She had memory issues and dementia. The patient had a diagnosis of schizophrenia. She had multiple intramuscular (IM) medications of Haldol, Ativan, and Benadryl. She continued with severe psychiatric symptoms and no adequate and comprehensive discharge follow up until she was discharged in which she was then psychiatrically, and medically stable and aftercare discharge was arranged including an alternative living arrangement.
     
The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Schizophrenia reports that patients with hallucinations, delusional thinking, disorganized thinking or behavior, severe agitation, aggression, or inability to adequately care for basic self-care needs are in need of hospital treatment. In this case she was unable to care for her basic self-care needs and had continued psychotic symptoms including disorganized thinking and severe agitation requiring as needed IM medications during the denial period. 

Notes reported that she was agitated, angry, guarded, loud, threw a bottle, was irritable and verbally abusive, and refused medications. She had loosening of associations, agitation, guarded, shouting, cursing. Other notes reported that she agitation, irritable mood, refusal of medications, talking to self, internal preoccupation, yelling, screaming, and pressured speech. Other notes reported that she was aggressive, loud, disorganized thinking and behavior, internal preoccupation, and poor insight and judgment. Notes reported that she had auditory hallucinations, refusal of medications, and had stat Haldol and Ativan. Notes reported that she had disorganization, aggressive and hostile behavior, loud speech, grabbing others, restlessness, and poor insight and judgment. Notes on reported that she was hostile, impulsive, auditory hallucinations, loud speech, irritable mood, pressured, loud, and rapid speech, and was unruly. Notes reported that she had ongoing agitation, loud speech, and disruptive behavior. Other notes reported that she was screaming, yelling, loud, and disruptive behavior. Notes reported physical aggression and was trying to kick staff. Notes reported that she was aggressive and a danger to others and had marked hypertension due to refusal of mediations and still had poor insight and judgment. Notes reported that she still required 1:1 observation and had medication refusal, was physically threatening others, had poor insight and judgment, and required IM Haldol and Ativan. 

Also, this was not considered custodial care as she still had acute and severe psychiatric symptoms including acute psychotic symptoms requiring acute psychiatric hospital treatment and reportedly improved enough for discharge in which she reportedly was then psychiatrically, and medically stable and aftercare discharge was arranged including an alternative living arrangement. She could not safely be treated outside of a 24-hour hospital treatment setting.  

Coverage for continued inpatient mental health treatment in this hospital should be approved. It did not appear that the health care plan acted reasonably or had sound medical judgment or acted in the best interests of the patient.

The insurer's denial of coverage for the continued inpatient mental health treatment, revenue code 0124, is overturned. Medical necessity is substantiated.