Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Substance Abuse and Mood Disorder.
Treatment:  Inpatient Mental Health Stay.

The insurer denied the Inpatient Mental Health Stay.  The determination is overturned.

The patient was admitted to acute inpatient psychiatric services for mood disturbance and psychosis in the context of substance use disorder with methamphetamine and cannabis.  The patient also used alcohol occasionally and was tobacco dependent.  The patient was brought in by police and emergency medical services due to threatening behavior at a homeless shelter.  He had been acting bizarre and was threatening, with increasing symptoms of psychosis that included paranoid thought content and the belief that he was at risk to be harmed.  The patient reported that he had not taken his medications.

The patient was admitted for an acute inpatient psychiatric evaluation and treatment after medical clearance that included physical examination, laboratory assessment and electrocardiogram (EKG).  His assessment included normal laboratory findings and a positive drug screen consistent with his use of cannabis (marijuana) and methamphetamine.  He was human immunodeficiency virus (HIV) positive and had a history of treatment for syphilis.

The patient has a history of psychiatric treatment and multiple hospitalizations for mood and psychotic disorder induced by substances.

On the mental status examination on admission, the patient was psychotic and cognitively impaired with disorganized thought processing and thought blocking.  He was delusional with paranoid thought content and was mentally confused with bizarre behavior and responses to internal stimuli.  He was guarded and uncooperative with poor eye contact.  He displayed irritable mood with anxiety, nervousness, apprehension, tension, irritability, and labile affect, and he indicated that he was having aggressive impulses but denied active suicidal or homicidal intent.  He demonstrated paranoid delusions and was hostile and aggressive with motor agitation.  He had decreased concentration, energy, sleep, and volition.

The patient was homeless and unemployed with ongoing substance use as noted.  There were no legal issues in this case.

The patient's treatment plan included safety monitoring and medication targeting mood disturbance and psychosis, as well as therapy and psychoeducation provided in the milieu.  Haldol and as needed (PRN) Ativan were prescribed for acute agitation and anxiety.  Other medications included hydroxyzine and Benadryl for anxiety and insomnia.  He was started on risperidone and Depakote to address the substance induced psychosis and mood disturbance.

The patient remained hostile, angry, tense and excitable with persistent paranoid thought content and delusions.  He was medication adherent but required ongoing re-direction from staff.

He was beginning to attend groups with encouragement.  He continued to display disorganized thought processing and had the onset of ruminations related to his homelessness and other psychosocial stressors.  He reported depression, fatigue and poor concentration due to amphetamine withdrawal.

The patient displayed improved mood with less anxiety and improved sleep, appetite and volition.  Discharge planning had occurred and disposition to the community with intensive services had been arranged with therapeutic shelter and plans for continued treatment with risperidone and Depakote at 1 milligram (mg) and 500 mg twice daily, respectively.  The patient was discharged with follow-up for his co-occurring psychiatric and substance use disorders with disposition to a shelter and recommendations for follow up for general medical care of his HIV positivity and recommendations for smoking cessation.

The issue under review is continued inpatient mental health stay.  The health plan documents and level of care guidelines were reviewed, as well as case records and correspondence from the health plan and the treatment facility.  The dates under review were denied certification of coverage by the health plan for continued inpatient level treatment on the basis of medical necessity.  This case is a New York State mandated review, with the application of NY State Office of Alcoholism and Substance Abuse Services (OASAS) Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) 3.0 Guidelines with regard to the co-occurring substance use disorders.

The mental health inpatient stay was medically necessary for this patient.  The patient's admission and the continued hospital stay for treatment of psychotic and mood disorder with co-occurring substance use disorders did require continued inpatient level services, structure, and monitoring through discharge.  The patient's severity of symptoms and safety concerns related to persistent symptoms of psychosis and mood disturbance were clinical factors and treatment dimensions that necessitated the continued acute inpatient hospital care, structure, and monitoring as proposed through discharge.  The medication management and safety monitoring together with attention to the precipitating issues in this case were medically necessary; the intensity of services and safety issues in this case could not have been effectively addressed or managed at a lower level of care.  Thus, medical necessity is met in this case scenario in keeping with the application of NY State OASAS LOCADTR 3.0 Guidelines/Criteria.  

These answers are consistent with the scientific literature and with prevailing standards of medical practice.