Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Mental Health 
Treatment: Inpatient Mental Health 
The insurer denied: Inpatient stay 
The denial is: Overturned in whole 

The patient is a male who was brought by emergency services to the emergency department on for evaluation of an acute exacerbation of schizophrenia. The patient had prominent delusions with internal preoccupation and paranoid themes. He reported command auditory hallucinations and had been acting strangely with unpredictable behavior prompting his brother to invoke a safety check. He had stopped his psychotropic medications and was noncompliant with his outpatient mental health treatment. He was noted to be in a debilitated state with mental confusion and decline in functioning representing a safety issue. Thus, the patient was subsequently admitted after medical clearance that included physical examination, laboratory assessment, chest x-ray, computed tomography (CT) scan of the head, and electrocardiogram (EKG). He was admitted for acute inpatient psychiatric services for treatment of the exacerbation of his chronic psychotic disorder best characterized as unspecified schizophrenia. 

Mental Status Examination on admission: The patient was guarded with poor eye contact and cognitively impaired with thought disorder and perceptual disturbance characterized by auditory hallucinations and preoccupation with internal stimuli. He displayed irritable and dysphoric mood with anxiety, nervousness, apprehension, tension, and excess worry together with ideas of reference to someone wanting to steal his money. He demonstrated disorganized thought processing with thought blocking and with content that was illogical and incoherent. He had decreased concentration, energy, and volition, and presented with impaired judgment, poor insight, and poor control of impulses with inability to care for self. 

The patient was noted to have continued evidence for conceptual disorganization, and he remained withdrawn and socially isolated with poor insight and impaired judgment requiring ongoing monitoring and assistance with activities of daily living. He reported craving and post-acute withdrawal symptoms that were mild. He received vitamin supplements and nicotine replacement therapy. He had prominent negative and positive symptoms of schizophrenia that persisted but diminished during the remainder of the inpatient stay. He was initially resistant to outpatient aftercare with continued evidence of poor insight and high risk for noncompliance. He was compliant with treatment and slowly began to attend groups that included educational sessions and social skills training. He showed gradual improvement in the disorganized thought processing, perceptual disturbance, and problems with executive functioning such that he began to require less direction and was more participatory in self-care. 

On the day of discharge, the patient was noted to be more stable with linear thought processing that was more logical, and goal directed. He was euthymic with fair to poor insight and judgment with better control of impulses. He denied hallucinations and demonstrated clear speech with better eye contact and communication skills. There were no remaining safety issues, and an aftercare appointment had been arranged with case management. He received an injection of Abilify Maintena with plans for continued use of the long-acting injectable medication in order to assure better compliance with his psychotropic medication. He was discharged to home with plans for medication management and outpatient level follow up. 

The health plan's determination is overturned in whole. 

The requested inpatient stay is medically necessary for this patient. The patient's continued hospital stay for treatment of an exacerbation of a psychotic disorder (schizophrenia) did require the continued inpatient level services, structure, and monitoring through discharge. The patient's severity of symptoms, and inability to effectively participate in treatment at a lower level of care, persistent functional impairment, and safety issues related to persistent symptoms of acute psychosis were clinical factors and treatment dimensions that necessitated continued acute inpatient hospital care, structure, and monitoring, as proposed through discharge. The medication management and safety monitoring together with attention to the family needs, the support of functioning and the continued application of multimodal treatments, as well as assurance of medication adherence, were factors that did warrant the continued inpatient level treatment through discharge; the patient could not have been effectively managed at a lower level of care during the time interval under review.