Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Depression, suicidal ideation, and an inability to function
Treatment: Continued Mental Health Inpatient Admission 
The health plan denied the requested continued mental health inpatient admission as not medically necessary.
The health plan's determination is overturned.

The case involves a young adult female admitted for acute inpatient psychiatric care. The patient presented with worsening symptoms of depression, suicidal ideation with plan to overdose, and an inability to function. She had comorbidity that included an anxiety disorder, an eating disorder associated with restrictive intake and poor appetite, post-traumatic stress disorder (PTSD) and borderline personality traits with severe psychosocial stressors that including childhood physical abuse, as well as sexual assault and childhood molestation. At the time of presentation, the patient was anxious and dysphoric with hopelessness, worthlessness, and prominent suicidal thoughts. She had diminished sleep, appetite, energy, concentration, and volition. However, the patient did endorse having nightmares and sleep paralysis, and was noted to have poor control of impulses and urges to self-harm with cutting, as she had a history of self-injury with cutting.

The patient remained depressed with thoughts of suicide and urges to self-harm, and bouts of affective instability. The patient's medications were adjusted with the discontinuation of Cymbalta and the addition of Effexor XR (extended release), together with Lamictal and Buspar with as needed (prn) use of Vistaril and Clonidine and Quetiapine, as well as the supplemental use of Xanax. She was receiving therapeutic interventions to address coping and relationship functioning with identification of triggers regarding self-harming behavior. She had improved mood and functioning with diminished anxiety noted on the day of discharge. The patient's thought processing and content had improved with a more hopeful outlook and improved insight, and the treatment team was discharge planning in keeping with a safety plan, disposition with roommate and family support, and with appropriate aftercare including arrangements for medication management and therapy to continue in an outpatient setting.

The health plan's determination of medical necessity is overturned, in whole.

Yes, the requested health service/treatment of continued mental health inpatient admission was medically necessary for this patient.

The patient's continued inpatient stay and treatment was reasonable and in the best interest of the patient; she had severe symptoms of depression complicated by PTSD, disordered eating and personality disorder with ongoing suicidal ideation and urges to self-harm in the context of affective instability. She had deteriorated to the point that she was unable to function with worsening symptoms of depression that persisted during the time interval under review. The patient also continued to pose a safety risk during the time interval under review as noted in the appeal and contrary to the denial determination. 

The patient's severity of symptoms, functional decline, and risk of relapse necessitated the continued acute inpatient care. The presenting and continuing symptoms of depressive disorder were not amenable to treatment at an alternate level of care during the time interval under review, in view of the worsening depression while in outpatient treatment with ongoing suicidal risk, disordered eating and maladaptive coping in association with borderline personality disorder. The patient's progress notes clearly indicate that the patient displayed continued symptoms that required inpatient level structure and monitoring for the duration of inpatient treatment. Specifically, she remained anxious with persistent symptoms of depression requiring medication adjustments or monitoring and intensive psychotherapy and counseling.