Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Bipolar mood disorder.
Treatment: Continued Inpatient Mental Health Treatment.

The insurer denied the Continued Inpatient Mental Health Treatment.  The denial is overturned.

The patient is an adult male. He was admitted for acute inpatient psychiatric treatment for an exacerbation of bipolar mood disorder. The patient had stopped his medications with subsequent recrudescence of mood disturbance and erratic and aggressive behavior requiring emergency medical services. He was threatening towards other while carrying a metal rod and making sounds as if he was shooting a gun. The patient had become acutely manic without overt psychotic features. He has a history of psychiatric hospitalizations with past episodes of mood disturbance that are often in the context of stopping his medications or medication non-adherence resulting in increased activity and dysphoric or irritable mood.

The patient had co-occurring substance use disorders including cannabis and alcohol use disorders with unspecified frequency and quantity of use.

The patient's mental status examination revealed motor agitation with irritable mood and labile affect, disorganized thoughts with pressured speech and racing thoughts, and with limited insight and impaired judgment and poor control of impulses. He was superficially cooperative and guarded and uncooperative. Sleep, energy levels and volition were disturbed. He was internally preoccupied with aggressive impulses together with poor impulse control.

The patient was admitted to inpatient level services with close observation and safety monitoring, structured milieu with programming, and resumption of pharmacotherapy with Abilify, and PRN (as needed) medications for agitation and anxiety and safety emergencies. He refused to resume treatment with Depakote or Abilify Maintena or Vraylar.

The patient was initially uncooperative with agitation and resistance to taking medication, and a difficult clinical course. The mental status examination remained unchanged.  He was hyperverbal, irritable, and had been labile with respect to mood and behavior and remained at risk for impulsivity due to limited insight and impaired judgment. He had become medication adherent with Abilify titrated to 15 mg (milligrams), and his family remained supportive but not actively involved in the treatment with regard to treatment planning and consideration of clinically appropriate aftercare.

The patient was deemed appropriate for discharge, and was improved with regard to mood and impulse control. The patient was discharged with plans to live with his friend and sublet an apartment, and continue treatment with PHP (partial hospitalization program) level care and intensive case management services (ICMS).

The health plan's denial was on the basis of InterQual Behavioral Health Criteria and plan coverage indicating that the patient had no safety issues (homicidal of suicidal ideation or intent) for the denied dates of service.

The appeal was on the basis of medical necessity and continued need for inpatient level structure, monitoring and the need to develop a safe and clinically appropriate discharge plan and disposition.

Yes, the Continued Inpatient Mental Health Treatment was medically necessary.

The patient's presentation and clinical features included an acute manic episode in the context of bipolar mood disorder and deterioration in functioning with safety issues and medication non-adherence, as well as severe cannabis use disorder and unspecified alcohol use disorder. The patient had failed to benefit from treatment with lower-level care, and was engaging in problematic and aggressive behaviors. The patient exhibited cognitive impairment (disorder thought processing and executive function) with deterioration in functioning in the context of impaired judgment, aggressive behavior, and limited insight. He had required intervention and emergency services to address his erratic and problematic behavior associated with severe symptoms of mania and disturbance of mood including homicidal threats.

The additional days/units of inpatient level service were warranted in order to effectively provide treatment and to work toward a safe and clinically appropriate disposition in accordance with prevailing standards of medical practice. Moreover, the additional days/units of inpatient level services were medically necessary in view of the history of relapse and non-compliance with his outpatient treatment and medication non-adherence and safety concerns with continued risk for harm to others or self. Thus, the time necessary for additional stabilization of mood and to arrange a clinically appropriate discharge from acute inpatient care is critical in this case to prevent another relapse and to safely provide for the transition/step down from acute inpatient level care to the community. The patient could not have been safely or effectively transitioned to a lower level of care during the time interval under review due to persistent symptoms of the mood disturbance, risk for substance use, and continued deficits with regard to insight and judgment.

In summary, medical necessity is met in this case consistent with prevailing standards of professional practice, and with published practice guidelines and the scientific literature, referenced below, as well as NY (New York) State instruction for this medical necessity review including the application of New York State OASAS (New York Office of Addiction Services and Supports) LOCADTR (level of care for alcohol and drug treatment referral) 3 Criteria. The denial reasons are not consistent with standards of care in this case in view of the clinical features and treatment dimensions necessary for effective management of the patient's co-occurring psychiatric and substance use disorders.

No, the health plan did not act reasonably, with sound medical judgment and in the best interest of the patient.

The requested service could not be safely or effectively provided with lower level care services in this case scenario, and, the patient was receiving active treatment that continued to be consistent with prevailing standards of professional medical practice. Thus, in keeping with NY (New York) State instruction for medical necessity reviews and LOCADTR (level of care for alcohol and drug treatment referral) Criteria, the requested benefit of continued inpatient admission through discharge should be covered under the plan. The continued inpatient admission is reasonable, clinically appropriate, and in the best interest of the patient, and was consistent with sound medical judgment and standards of medical practice, as well as New York State instruction for this review.