Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Suicidal Ideations.
Treatment: Acute Psychiatric Inpatient Care.

The insurer denied coverage for acute psychiatric inpatient care. The denial is overturned.

This patient reportedly was admitted to this inpatient hospital due to worsened depressive symptoms, including depressed mood, hopelessness, anhedonia, suicidal thoughts with intrusive thoughts of jumping off the bridge, sleeping problems, concentration problems, poor hygiene, decreased energy, constricted affect, and loneliness. The patient reportedly had a history of self-injurious behavior, including cutting as recently as within four months before admission. The patient reportedly had three recent psychiatric hospitalizations, including one for intrusive suicidal thoughts and depression, and reported five total past psychiatric hospitalizations. The patient reportedly was referred by their primary care provider staff due to the intrusive suicidal thoughts of jumping off the bridge and worsened depressive symptoms. The patient reportedly also has Autism Spectrum Disorder, anxiety, and obsessive-compulsive symptoms. It was reported that the patient did not want to live due to their autism and social difficulties. The patient reportedly had medication changes and additions and seven electroconvulsive therapy (ECT) treatments while in the hospital. The patient reportedly eventually improved and was discharged.
 
The reviewer disagrees with denying coverage for inpatient hospital treatment as the medical records provided enough specific evidence to support that the patient required inpatient hospital treatment. The patient was considered a high-risk patient for suicide due to their severe depression with intrusive suicidal thoughts of jumping off the bridge on admission and the active treatment plan still during the denial period and lack of adequate treatment upon discharge from this hospital. The patient reportedly was started on Lithium to try to prevent depression from worsening after completion of ECT treatments. The first denial date was the last day of ECT treatment and the first day of Lithium treatment. Even though the patient reportedly had improvement and denied suicidal thoughts, they required this medication to prevent another psychiatric hospitalization upon discharge as they reportedly had three recent psychiatric hospitalizations due to the same clinical presentation of intrusive suicidal thoughts and worsened depression and had five past psychiatric hospitalizations. Also, there was not adequate discharge treatment as the patient was turned down from two partial hospitalization programs (PHPs) and was finally accepted to a PHP to start over a week later. The patient needed a transition appointment, as the patient was considered at high risk for decompensation without a multimodal, supervised, and structured partial hospital program (day treatment). This patient was considered a high-risk patient with multiple past reported recent psychiatric hospitalizations who had an active psychiatric treatment plan still, including adding Lithium on the first denial day. 

The patient had a cross taper of Escitalopram, which was eventually discontinued, Venlafaxine was started and titrated, and Abilify decreased. Clomipramine was discontinued, and Lithium was added while starting ECT. The patient needed more time in this 24-hour inpatient hospital treatment while still having an active psychiatric treatment plan, which included medication changes and without adequate discharge to a multimodal PHP program. As a result, the recommendation is to reverse the previous decision and approve coverage for continued inpatient psychiatric hospital treatment.

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

The medical necessity for acute psychiatric inpatient care is substantiated.