Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Suicidal thoughts, plans, intent, and attempts

Treatment: Continued inpatient mental health treatment. 

The insurer denied coverage for continued inpatient mental health treatment. The denial was upheld.

This patient is a male was admitted to this inpatient mental health treatment in this hospital due to; suicidal thoughts, plans, intent, and attempts as it was reported that he had a suicide attempt the night prior to admission by taking an overdose of his girlfriend's blood pressure medications and tried to stab himself in the throat with a knife five days prior to this admission. He had depressed and irritable mood, poor impulse control, sleeping problems, paranoia, visual hallucinations, and outbursts. He had a diagnosis of Major Depressive Disorder. He was prescribed the following medication: Lexapro, Remeron, and Zyprexa. He was discharged.

The insurer denied coverage for continued inpatient mental health treatment in this hospital as not medically necessary treatments. They stated that he did not require 24 hour hospital treatment, and they recommended a less restrictive level of care.

This reviewer agrees with the decision to deny coverage for continued inpatient mental health treatment in this hospital as the medical records did not provide enough specific evidence to support that he still only required this acute psychiatric hospital level of care or that he could not be safely and effectively treated in a less restrictive level of care. The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Major Depressive Disorders indicates that the least restrictive level of care for safe and effective treatment is appropriate and that patients with suicidal plan or intent or behaviors, or inability to adequately care for basic needs are candidates for inpatient level of treatment.

He reportedly had suicidal thoughts, plans, intent, and attempts prior to admission and required and received 24 hour acute psychiatric hospital treatment. However, the medical records for a specified service date did not report further suicidal ideation, intent, plan, or behavior. The notes on a specified date reported that he denied suicidal ideation, was eating and sleeping better, and stated that if he were to have suicidal thoughts or worsened depression that he would tell someone.  The notes reported that he was calm and compliant, withdrawn, guarded, with poverty of speech, but denied suicidal or homicidal ideation, plan, or intent, or hallucinations. The notes reported that he no longer was endorsing suicidal ideation.  He was discharged.  

As of a specified date there were no reports of suicidal or homicidal ideation, intent, or plan, inability to adequately care for basic needs, manic episodes, psychotic symptoms, self-injurious, aggressive, threatening, or agitated behavior. As of a specified date the chart notes did not provide specific evidence that he was an imminent danger to self or others or unable to adequately care for his basic needs. Also, there were no reports of specific identifiable or quantifiable treatment goals or objectives that could only be achieved in a 24 hour acute psychiatric hospital setting or that could not be achieved in a less restrictive setting.  

As a result, the determination is to uphold the previous decision and deny coverage for inpatient mental health treatment at this hospital. It appeared that the health care plan acted reasonably and with sound medical judgment and in the best interests of the patient.

Based on the above information, the medical necessity for the continued inpatient admission is not substantiated.  The insurer's denial is upheld.