Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Severe depressive symptoms 

Treatment:  Continued Inpatient Admission 

The insurer denied the continued inpatient admission.  The denial was upheld. 

This is a female patient with a history of Major Depressive Disorder, posttraumatic stress disorder (PTSD), psychiatric hospitalizations, inpatient substance detoxification/rehabilitation treatments, and three attempted suicides.  She presented to the hospital with complaints of severe depressive symptoms including depressed mood, suicidal ideation, anhedonia, increased sleep, decreased motivation and energy, feelings of hopelessness, decreased appetite, social withdrawal, and concentration problems.  It was reported that she had stopped taking her psychotropic medications due to increased insurance coverage issues.  She was restarted on Cymbalta with a positive response.  It was noted that several days after the initiation of the Cymbalta, the patient denied suicidal or homicidal ideations, hallucinations, and was compliant with medication administration.  She was able to use coping skills and identify triggers to negative thoughts.  She was discharged home with outpatient mental health treatment follow up.  The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Major Depressive Disorders reports that the least restrictive level of care for safe and effective treatment is appropriate and that patients with suicidal plan or intent or behaviors, or inability to adequately care for basic needs are candidates for hospitalization. 

Several days into her admission there were no reports of suicidal ideation, plan, or intent, severe depressive symptoms, inability to care for basic needs, aggressive or self-injurious behavior, psychotic symptoms, substance use problems or substance withdrawal, or acute medical instability.  The notes reported that she denied suicidal or homicidal ideation, she had hope for the future, slept well, and her negative thoughts resolved.  Further notations reported that she denied suicidal or homicidal ideation, hallucinations, was in behavioral control, had no acute issues, was compliant with medications, was using coping skills to discuss feelings, and was able to identify triggers to negative thoughts.  Several days prior to discharge it was reported that she denied suicidal or homicidal ideation, hallucinations, and she was in behavioral control, medication regimen adherent, and had no acute issues and  that she denied suicidal or homicidal ideation or wishes to be dead, had a less depressed and anxious mood, had fair insight and judgment, denied hallucinations, had goal directed thought process, was ready to handle things, and she denied negative thoughts, and was compliant with medications.  She was discharged home. 

Several days into her admission, there were no reports of suicidal or homicidal ideation, intent, or plan, inability to adequately care for basic needs, manic episodes, psychotic symptoms, or self-injurious, aggressive, threatening, or agitated behavior.  The chart notes did not provide enough specific evidence that she was an imminent danger to self or others or unable to adequately care for her basic needs.  Also, as of then, there were no reports of specific identifiable or quantifiable treatment goals or objectives that could only be achieved in a 24- hour acute psychiatric hospital setting or that could not be achieved in a less restrictive setting. 

The health care plan acted reasonably and with sound medical judgment and in the best interests of the patient. 

The carrier's denial of coverage for the continued inpatient hospital admission is upheld.  The medical necessity is not substantiated.