Appeal type: Medical necessity
Decision: Overturned

Mental Health 
Inpatient Mental Health

Diagnosis: Bipolar I Disorder
Treatment Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is overturned.

The patient was admitted for acute inpatient psychiatric treatment. He  presented to the emergency department with suprapubic pain and urinary retention requiring emergency services. He was later found to have a urinary tract infection. While in the emergency department, he reported that he had become increasingly depressed with suicidal ideation with a plan. He reported deterioration in functioning and had stopped his psychotropic medication four months earlier. He has a history of bipolar disorder with severe depressive episodes and psychiatric treatment with therapy and medications, as well as past treatment for co-occurring substance use disorders. 
The mental status examination revealed dysphoric mood with anxiety including apprehension, nervousness, tension, irritability, and excessive worry. Sleep, appetite, energy levels and volition were disturbed.  He was withdrawn with motor agitation and was irritable and demanding and uncooperative with the psychiatric evaluation. There was no psychosis or other signs of cognitive impairment, but he reported perceptual disturbance with command auditory hallucinations. Judgment was markedly impaired, and suicidal risk was judged to be moderately severe.
There are no legal issues or trauma/abuse history reported in this case. 
The patient was admitted with plans for close observation, safety monitoring, structured milieu therapy, and pharmacotherapy with Seroquel, Depakote and Prozac, as well as vitamin and nicotine replacement therapy. He continued to exhibit mood disturbance with dysphoria and labile affect. He had bouts of mood cycling with argumentative and demanding behavior, loud speech, poor concentration, and persistently impaired judgment and limited insight. He denied active suicidal ideation and the auditory hallucinations resolved. He was medication adherent with tolerability. 
The patient's mood improved and he continued to take medications without adverse effect. He denied suicidal ideation, plan or intent. 
The patient was discharged from inpatient level care with step down to the community for clinically appropriate aftercare.

The continued acute inpatient level structure and monitoring is reasonable in view of the patient's severe symptoms of mood disorder and co-occurring substance use disorders; in view of the severe psychosocial stressors in this case with limited social supports; and, in view of the need for continued active treatment in the context of deteriorated functioning.
Additionally, the inpatient stay during the time interval under review is medically necessary in order to monitor the response to medications, to insure that the patient will have a sustained response to treatment, and to continue to address the acute risk of suicidal behavior in the context of severe symptoms of bipolar mood disorder with depression and irritability and the co-occurring substance use disorders that also required motivational techniques and counseling. The necessity for the admission and the continued inpatient level services reflects sound medical judgment in keeping with prevailing standards of professional practice, and with the published practice guidelines and criteria as well as the application of NY State Office of Alcoholism and Substance Abuse Services (OASAS) Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) Criteria.