Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Psychotic Episode

Treatment: Behavioral health hospital admission
 
The insurer denied the behavioral health hospital admission

The denial was overturned.

This is a male patient who was admitted to this inpatient mental health treatment at this hospital due to psychotic and manic symptoms, and suicidal threats.  He was physically aggressive, threatening others, threatening to kill self and hurt his sister, had poor impulse control, severe agitation, paranoid and grandiose delusional thinking, internal preoccupation, intrusive thoughts, noncompliance, irritable mood and was argumentative.  He had a history of Schizoaffective Disorder with multiple prior psychiatric hospitalizations. It was reported that he was homeless. He received intramuscular Haldol and Ativan as needed. He continued to refuse medication and was eventually discharged.

This reviewer disagrees with the decision to deny coverage for continued inpatient mental health treatment at this hospital as the chart notes provided enough specific evidence to support that he still required hospital treatment. The InterQual 2019 Behavioral Health-Adult and Geriatric Psychiatry-Inpatient medical necessity criteria reports that if one has assaultive behavior within 24 hours, catatonia, command hallucinations to harm self or others, destruction of property with poor impulse control within 24 hours, disorganized behavior, unstable eating disorder, fire setting, homicidal or suicidal attempt within 24 hours, suicidal or  homicidal ideation with high risk for an attempt, mania, risk of harm to self or others, non-suicidal self-injury and continued danger to self, then inpatient care is needed. It also states that positive psychotic symptoms with risk of harm to self or others, posttraumatic stress disorder (PTSD) with risk of harm to self or others, psychomotor agitation and potential for violence, severe social withdrawal and refusing treatment, unavailable support or inability to provide needed care and supervision and there is acute deterioration in functioning, then criteria for inpatient treatment is also met.  Also, if symptoms improved but the patient was not clinically stable for discharge or was a high risk for re-hospitalization or a high risk of harm to self or others, then criteria would still have been met.  

In this case, the chart notes did report that he refused medications and lacked insight into his illness as he stated that he was not mentally impaired and did not need the medications.  Without the medications, he likely would have experienced worsening of his psychotic, manic and behavioral symptoms and would likely require hospitalization again; therefore, premature discharge would not be in this patient's best interest.  Even though he had some improvement in symptoms, he was not clinically stable for discharge as he refused medications and thought he had no mental illness.  Notes also reported that he refused medications.

The patient had presented on admission with suicidal threats and homicidal thoughts, aggressive and threatening behavior, severe agitation, paranoid and grandiose delusional thinking, internal preoccupation, intrusive thoughts, non-compliance, irritable mood, and was argumentative. He was considered a high risk patient who required continued 24-hour hospital treatment.  He continued to require and receive active psychiatric hospital treatment as the staff was trying to encourage him to take the medication he needed to target mood and psychotic symptoms. He was discharged
The health care plan did not act reasonably, or with sound medical judgement, or in the best interest of the patient.

The carrier's denial of coverage for the continued inpatient behavioral health hospital stay is overturned.  The medical necessity is substantiated.