Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Depression, Suicidal Behavior
Treatment: Inpatient Psychiatric Stay
The insurer denied the Inpatient Psychiatric Stay.
The determination is overturned.

The patient was admitted to acute inpatient level psychiatric services with severe symptoms of depression and anxiety associated with psychosis, suicidal behavior/risk and impaired functioning. The patient experienced a mental breakdown previously prompted by workplace stress and culminating in a suicide attempt by overdose. His breakdown followed a change in medication without benefit and with worsening symptoms of depression. He became paranoid with delusions thinking that he would be arrested for mistakes made at his workplace. His delusions resulted in persistent suicidal ideation with plans to electrocute himself or overdose or cut his wrists.
Despite ongoing treatment in the community with his primary and specialty care physicians, the patient's mood worsened with associated symptoms of depression and profound hopelessness with morbid preoccupations together with the delusions and treatment refractory depression that did not respond to medication or transcranial magnetic stimulation (TMS) therapy. He was focused on the fear of being incarcerated with thoughts that he would be better off dead. He was admitted to inpatient level psychiatric services for a comprehensive psychiatric evaluation and treatment and safety monitoring.
The patient has a history of general medical co-morbidities that includes gastroesophageal reflux disease (GERD) and headaches with associated treatments. Laboratory assessments were normal or unremarkable with a negative drug screen. There is no active substance use disorder in this case.
The patient is married and lives with his spouse. There were no legal issues in this case and no history of trauma or abuse. The patient is employed with workplace stress and declining performance prior to his breakdown.
On Mental Status Examination on admission, the patient was cooperative and tearful with motor retardation and slowed mentation. He displayed depressive demeanor and expressed morbid ruminations with delusions, as noted. He displayed depressed mood with anxiety and cognitive clouding. He had decreased concentration, energy, appetite, sleep, and volition. His speech was coherent with linear thought processing and morbid content with active suicidal ideation and auditory hallucinations of dogs and police helicopters overhead searching for him. Insight and judgment were limited and fair with minimization. He displayed hopelessness, helplessness, guilt, shame and low self-worth indicating that he was exhausted and unable to function.
The patient was admitted to acute inpatient level care with safety-monitoring, access to group and milieu therapies, and medication adjustments in order to address the anxiety, depression, psychosis and sleep disturbance. The patient was initially noted to be severely depressed and socially withdrawn. Medications were adjusted to include Zoloft, risperidone, and trazodone with as needed (prn) use of Vistaril for anxiety.
The patient continued to display delusional thinking and indicated that he was soon to be arrested; he was unable to be reassured that this would not happen despite ongoing treatment. He received cognitive behavioral therapy (CBT) and dialectical behavior therapy (DBT) interventions, as well as family sessions with his spouse. He did gradually improve with regard to mood and anxiety such that he was able to deny the delusions involving workplace and was more hopeful with a forward-looking outlook. His medications had been adjusted during this time frame with an increase in risperidone resulting in gradual reduction in his psychotic thought content. Discharge planning had occurred; he declined step down to Partial Hospitalization Program (PHP) level care, but was referred to outpatient aftercare. Discharge diagnoses included severe and recurrent major depressive disorder with psychotic features and unspecified anxiety disorder. Discharge medications included Zoloft 100 milligrams (mg), risperidone 1 milligrams (mg) in the AM and 1.5 mg at bedtime together with 250 mg of trazodone and continued use of Vistaril as needed for anxiety or agitation.
During the time interval under review, the patient remained psychotic, but by the date of discharge had gradually responded to treatment with diminished intensity of depressive symptoms including diminished anxiety and better functioning; the patient was better focused and displaying better judgment with improved mood and brighter affect. He no longer felt overwhelmed or hopeless, and he was medication adherent with tolerability. A discharge conference had occurred with discharge planning, and he was discharged to home with clinically appropriate aftercare in collaboration with community clinicians to include continued therapy and medications.
At issue is the medical necessity of Acute Inpatient Psychiatric Services.
The requested health service/treatment of psychiatric disorder treatment- acute inpatient level of care was medically necessary for this patient.
The patient's symptoms of depression and anxiety together with impaired functioning and risk for suicide warranted the admission and the continued acute inpatient level structure and monitoring through discharge. The case is complicated by severe psychosocial stressors related to the patient's preoccupation with workplace performance with a breakdown that included psychosis and suicidal ideation in the context of treatment refractory depression. The symptoms of mood disorder and associated symptoms of anxiety; continued risk for suicide, psychosocial stressors; and, treatment issues related to medication adjustments and need for monitoring, and the need for arranging a safe and appropriate discharge plan warranted the continued services at an acute inpatient level of care. The patient had worsened and declined in functioning despite having access to treatment in the community with outpatient level services. These clinical factors support the medical necessity for the continued acute inpatient level structure and 24-hour monitoring through the day of discharge when the patient had reached a level of stability that he could return home with family with clinically appropriate follow-up and aftercare.
This answer is consistent with the scientific literature and published guidelines, referenced below, as well as prevailing standards of medical practice.