Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Command auditory hallucinations 

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission. The denial is upheld. 

This patient is a male who was admitted to this inpatient mental health treatment in this hospital due to command auditory hallucinations to hurt self and others, paranoid delusional thinking as he thought his neighbors were going to harm him and that they were stealing his medication, and he had reports of harm to self or others, threatening behavior, non-compliance, and it was reported that he tried to jump out of the car on the way to the hospital.  He had a diagnosis of Schizophrenia. He took Haldol Decanoate, Cogentin, and Ambien.  He had dispositional problems and was discharged. The insurer denied coverage for continued inpatient mental health treatment.

This reviewer agrees with the decision to deny coverage for continued inpatient mental health treatment in this hospital as not medically necessary treatment as there were no medical records with specific evidence to support that he still had severe psychotic symptoms, suicidal or homicidal ideation, or threatening behavior requiring 24 hour psychiatric hospital treatment then.  

The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Schizophrenia report that patients with hallucinations, delusional thinking, disorganized thinking or behavior, suicidal or homicidal plan or intent, agitation, or aggressive behavior are candidates for inpatient treatment.  In this case as of a specified date there were no reports of psychotic symptoms such as delusions, hallucinations, or disorganized thinking or behavior, suicidal or homicidal ideation, intent, or plan, manic symptoms, aggressive, threatening, self-injurious, or agitated behavior, withdrawal symptoms or acute medical instability.  Notes on the specified date above reported that he was not presenting with psychotic symptoms.  There were no reports of command auditory hallucinations, suicidal or homicidal ideation.  Notes on the following specified date reported that he was compliant, social with others, had good appetite, and there were no reports that he had psychotic symptoms, suicidal or homicidal ideation or threatening behavior.  He remained due to placement issues. Notes reported that he did not have behavioral management problems, was attending groups, and he took Haldol Decanoate as he was compliant with medication.  He was discharged.  There were no reports of acute or severe mental health or behavioral symptoms that required 24 hour acute hospital treatment as of a specified date.  As of that date 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 treatment setting as of then or that could not be achieved in a less restrictive level of care as of then. 

As a result, the recommendation is to uphold the previous decision and deny coverage for continued inpatient psychiatric treatment in this hospital.  It appeared that the health care plan acted reasonably and with sound medical judgment and in the best interests of the patient then.

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