Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Major Depressive Disorder

Treatment: Inpatient hospital admission 

The insurer denied coverage for inpatient hospital admission 

The denial is overturned.

According to the documentation submitted, this is a patient with no past medical history who presented to the emergency department by ambulance from a friend's house, for evaluation due to suicide attempt by ingestion of 5 Advil tablets. She stated she was feeling sad and had an argument with her boyfriend.  Psychiatry was consulted and reported that she exhibited depressive symptoms which included depressed mood, decreased interest and energy, hopelessness, crying, sleeping and appetite issues, poor judgment. Psychiatry stated she had major depressive disorder and was at risk for suicide as she had suicidal thoughts and depression and recommended 1:1 direct observation. She had a positive toxicology for cannabinoids. She was discharged the following day with a referral for outpatient mental health treatment.

The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Suicidal Behaviors reports that patients with suicide attempts are at high risk of suicide. Suicide attempts are the single most reliable predictor of suicide. This patient was considered at risk due to an intentional overdose of 5 Advil pills and had reports of suicidal thoughts and major depressive symptoms including depressed mood, decreased interest and energy, hopelessness, sleeping and appetite issues, poor judgment, and had multiple stressors including financial and interpersonal stressors as well as having an argument with her boyfriend. This patient was considered a danger to self, due to a suicide attempt with depression, so she required the hospital time. She reportedly was on 1:1 observation. Also, the Milliman Care Guidelines (MCG) Behavioral Health-Adult-Inpatient Level of Care guidelines reports that one needs one of the following: presenting as an imminent danger to self, imminent danger to others, severe psychiatric or behavioral symptoms, a severely dysfunctional living including inability to care for self, unwilling to participate voluntarily, or if a less restrictive level of care is not feasible meet criteria for inpatient behavioral health level of care. 

In this case, the patient was considered a danger to self due to a suicide attempt with major depressive symptoms and required another day of observation in this hospital as she was considered a risk of harm to self if discharged prematurely. It was reported that she was sobbing when asked questions about suicide. It was reported that she had depressive symptoms for months and it worsened after recent stressors. She reportedly denied suicidal thoughts or depression but it was considered standard and appropriate treatment to observe her while denying depressive symptoms or suicidal thoughts as the APA Practice Guidelines for the Treatment of Patients with Suicidal Behaviors reports also that patients may require more time in the hospital to better assess suicide because they sometimes do not tell the truth regarding their suicidal thoughts in order to leave the hospital and that observation in the hospital is appropriate to better ensure their safety.  

The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for the inpatient hospital admission is overturned. Medical necessity is substantiated.