Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Suicidal Behavior, Depressive Disorder
Treatment: Inpatient Mental Health Stay.
The insurer denied the Inpatient Mental Health Stay.
The determination is overturned.

The patient was admitted for acute inpatient level care with symptoms of depression and self-harming behavior. She had an argument with her husband with fear that he was cheating which resulted in the patient cutting her wrist. She was brought to the emergency department for treatment of the wrist laceration and a psychiatric evaluation in the context of severe psychosocial stressors. The patient presented with a history of depressive disorder and prior treatment with antidepressant medications. She indicated that the medications were not working and were not well tolerated.
At the time of presentation, the patient was tearful with symptoms of anxiety and depressive demeanor and preoccupation with her situational stressors. She had depressed mood with sadness, anger, and anxiety and reported low energy with decreased concentration and volition. There were no symptoms of mania, thought disorder, psychosis or severe cognitive impairment though she did display lethargy and fatigue. Insight was limited and poor, judgment was impaired, and impulse control was questionable. The patient denied prior hospitalization or suicidal or self-harming behaviors. There were no acute general medical problems or current substance use disorders in this case.
The patient is married and employed on a part time basis, and lives with her mother and husband. There was no trauma history or legal issues in this case. There is a family history of depression. The patient's father had recently died which was a perpetuating factor for the depression, and there was conflict with the husband, as noted.
The diagnoses included major depressive disorder, recurrent and unspecified, history of social anxiety disorder, and severe deterioration in functioning that included suicidal risk and severe psychosocial stressors.
The patient had received a comprehensive medical evaluation prior to admission. She received eight stitches to address the laceration. Laboratory assessments and an electrocardiogram (EKG) were normal. She was admitted with subsequent safety monitoring and treatment with milieu therapy that included group, educational and activity therapies. She received medication with the use of Effexor with plans to titrate as clinically appropriate, and as needed (prn) medications to address anxiety and insomnia. She engaged in therapeutic interventions with safety monitoring and support from her mother. The treatment team and case manager were working to develop a safe and clinically appropriate discharge plan and disposition in concert with the patient's mother.
By the last day of her brief inpatient stay, the patient was noted to be adherent to medication and participating in the therapeutic interventions. She was calmer with normal speech that was clear and thoughts that were linear and logical, as before. She denied suicidal ideation or any urges to self-harm. Discharge planning had occurred and the patient was discharged with clinically appropriate aftercare and continued medication (Effexor titrated to 75 milligrams (mg) daily), as well as the safety plan developed in concert with her mother with whom she lived and follow up appointments for continued mental health services.
At issue is the medical necessity for acute inpatient treatment for dates of service.
The health plan documents and appeal documents were reviewed, as well as correspondence from the health plan and treatment facility, health plan medical necessity criteria, certificate of coverage were reviewed, as submitted. This review is New York State mandated review.
At issue is the medical necessity of an inpatient stay.
The requested health service/treatment of inpatient stay was medically necessary for this patient.
The patient's acute inpatient treatment was clinically appropriate, reasonable, and in the best interest of the patient. She had severe symptoms of depression, she was a safety risk with the need to address the mood disorder and precipitating factors resulting in the impulsive self-harming behavior, and outpatient treatment had failed to prevent the worsening symptoms of depression with the onset of severe symptoms in the context of severe psychosocial stressors and the conflict with her husband. The patient remained a safety risk and functionally impaired with a high risk for relapse or self-harm or suicide; and the patient needed to reach a stable baseline of functioning with assurance of medication tolerability with a solid disposition and safety plan prior to discharge from inpatient level care.
Thus, it was medically necessary for this patient with major depressive disorder and safety concerns to remain in the acute inpatient setting in order to continuously assess her risk of suicidal or impulsive behaviors, and to address the acute risks of a return to the community with the noted functional impairments and treatment issues, as well as the need to develop a safe and clinically appropriate discharge plan and disposition with clinically appropriate aftercare.
These answers are consistent with prevailing standards of professional practice, the scientific literature, and published practice guidelines, referenced below.