Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Major Depressive Disorder

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is overturned

This patient reportedly was brought in by ambulance accompanied by their sister after making suicidal remarks, expressing suicidal thoughts as they did not want to live, and had worsened depression including depressed mood, withdrawn, and tearfulness. The patient reportedly had stressors including the anniversary of the death of their child. The patient reportedly had past suicide attempts including drinking a bottle of bleach and also an attempt in which they took their mother's pills. The patient reportedly was admitted to the psychiatric unit in the hospital due to being at risk of imminent danger to self due to worsened depressive symptoms including suicidal thoughts with a history of past suicide attempts. The patient reportedly was found to be hypotensive with a blood pressure of 66/43 and there was suspicion of hypovolemic shock versus sepsis. The patient was transferred to the medical unit and given intravenous (IV) fluids, worked up with blood cultures and blood work up, put on close monitoring, and 1:1 for suicidal thoughts. The patient reportedly was vomiting and could not tolerate oral hydration. The patient reportedly had a medical history significant for seizures, asthma, and had hypotension. The patient reportedly had mental status changes. The patient reportedly had a diagnosis of Major Depressive Disorder. The patient reportedly was taking Escitalopram for depression. The patient reportedly was cleared medically and transferred back to the psychiatric unit for further inpatient psychiatric hospital treatment then due to them being considered a danger to self and others due to their depressive symptoms with suicidal thoughts and history of past suicide attempts.

The reviewer disagrees with the decision to deny coverage for inpatient hospital treatment as the medical records provided enough specific evidence to support that they required hospital treatment then. The Milliman Care Guidelines (MCG) Behavioral Health Inpatient Level of Care Adult criteria reports that a patient needs to present as an imminent danger to self, imminent danger to others, with severe psychiatric or behavioral symptoms, have a severely dysfunctional living including inability to care for self, unwillingness to participate voluntarily, or a less restrictive level of care is not feasible meet criteria for inpatient behavioral health level of care. In this case it was reported that this patient had worsened depressive symptoms with suicidal thoughts and remarks with a history of past suicide attempts including drinking a bottle of bleach and also taking his mother's medications, so the patient was considered an imminent danger to self and in need of 24-hour hospital treatment then. The patient had medical issues while on the psychiatric unit including hypotension with a blood pressure of 66/43 with vomiting and inability to tolerate oral hydration and with mental status changes so the patient required medical treatment and was transferred to the medical unit. The patient reportedly received IV fluids and had a medical work up for hypovolemic shock verses sepsis and was on 1:1 observation due to suicidal statements. 

Also, the American Psychological Association (APA) Practice Guidelines for the Treatment of Patients with Suicidal Behaviors reports that patients with past suicide attempts are at high risk for suicide and this patient had past reported suicide attempts including by drinking a bottle of bleach and taking their mother's medications and had worsened depressive symptoms related to the anniversary death of their child so they were considered at higher risk for suicide and in need of 24 hour hospital treatment.

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for inpatient hospital admission is substantiated.