Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Overdose

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is overturned

This an adult patient who was admitted to the hospital due to a serious suicide attempt by ingesting multiple 40 milligrams (mg) of Prozac pills and 15 mg of Buspirone pills. The patient reported that this was an attempt to commit suicide as the patient was depressed due to the termination of the relationship with a significant other. The patient vomited, was drowsy and tired. The patient had diagnoses of Major Depressive Disorder, Borderline Personality Disorder and Bulimia Nervosa. The patient reported drinking alcohol. The patient was admitted to the medical floor due to being at risk for QTc prolongation and being considered a high suicide risk according to the psychiatric consultant. The patient had the home medications held, was given continuous intravenous (IV) fluids, had continuous telemetry monitoring, and was transferred to the psychiatric unit for involuntary admission once medically stable.

The insurer denied coverage for inpatient hospital treatment stating that the patient did not warrant inpatient hospital treatment. They recommended a less restrictive level of care.

The reviewer disagrees with the decision to deny coverage for inpatient hospital treatment as the medical records provided did support that the patient required inpatient hospital treatment. The Milliman Care Guidelines (MCG) Drug Ingestion or Overdose criteria reports that one meets criteria if one of the following are met: hemodynamic instability, dangerous arrhythmia, respiratory abnormalities, hypertension requiring inpatient treatment, specific finding indicating severe and prolonged drug toxicity, or inpatient admission is required other than observation care. 

The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Suicidal Behaviors reports that patients with suicide attempts are at high risk of suicide. Suicide attempts are the single most reliable predictor of suicide. This patient was considered an imminent danger to self due to an intentional overdose of Prozac and Buspirone in a suicide attempt, having major depressive symptoms and poor coping skills in response to a stressor of the significant other ending their relationship. The patient was minimizing the symptoms, the suicide attempt and was aloof. The patient was also at medical risk due to the large amount of serotonin ingestion and was at risk for serotonin syndrome and for prolonged QTcs. The patient was at risk for suicide due to past reported suicidal behaviors, poor insight and judgment, lack of engagement in treatment. The patient had a diagnosis of Major Depressive Disorder-severe-recurrent in addition to Borderline Personality Disorder. The APA Practice Guidelines for the Treatment of Patients with Suicidal Behaviors reports that patients may require more time in the hospital to better assess suicide because they sometimes do not tell the truth regarding their suicidal thoughts in order to leave the hospital. The APA Practice Guidelines also state that observation in the hospital is appropriate to better ensure their safety. The patient was considered an imminent danger to self and in need of inpatient hospital treatment. Even though the patient was not in an acute psychiatric hospital, the patient still required 24-hour inpatient hospital treatment due to the suicide attempt. As a result, the recommendation is to overturn the previous decision and approve coverage for inpatient hospital treatment. The patient was transferred to the psychiatric unit once deemed medically stable. 

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for the inpatient admission is substantiated.