Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Depression

Treatment: Continued inpatient mental health stay

The insurer denied coverage for continued inpatient mental health stay

The denial is upheld.

This teen reportedly identifying as a transgender male was admitted to this inpatient psychiatric hospital due to mood symptom. It was reported that the patient had a suicide attempt by overdose of Tylenol and Claritin and was on the medical unit for 2 weeks before being admitted to the psychiatric unit. The patient was discharged from that hospital with a recommendation to go to another hospital. The patient then went to psychiatric center. The patient had manic symptoms of racing thoughts, increased speech, disorganized thoughts, elevated mood, and poor sleep for days. The patient had these symptoms after an increase in the Lexapro dosage. The patient was taking Quetiapine, Lexapro, Trazodone, Propranolol, Benadryl, and Melatonin. The patient reportedly attended group and individual therapy and had cognitive behavioral therapy (CBT) and dialectical behavior therapy (DBT). The patient was discharged.
  
The Milliman Care Guideline (MCG) Behavioral Health Level of Care Child-Adolescent Psychiatry medical necessity criteria reports that one needs to present as an imminent danger to self  or others with an imminent risk of suicide attempt or serious harm to self or homicidal behavior or harm to others, current suicidal or homicidal plan or plans of harm to self or others, command auditory hallucinations suicidal or self-harm in nature or homicidal or with harm to others, or persistent thoughts of suicide or self-harm or violent impulsive acts likely to result in homicide or serious harm to others that cannot adequately be monitored at a lower level of care,  severe psychiatric or behavioral symptoms with either bothersome hallucinations or delusions, disorganized speech, bizarre or catatonic behavior, severe negative symptoms, severe mania, depression, anxiety, or comorbid substance use with inability to control use, severe impairment in cognition, memory, judgment, or impulse control, aggressive behavior or severe agitation, or a severely dysfunctional living environment, or inability or unwillingness to be treated at a less restrictive level of care. 

The patient had manic symptoms and past suicidal thoughts and a recent suicide attempt which prompted a psychiatric hospitalization but as of later date, there was no specific documented evidence to support that only acute psychiatric hospital treatment was required. Notes reported that the patient did not have suicidal thoughts or plans and was free from suicidal thoughts or plan. Notes reported that the patient was doing well and discussing feelings. It also reported that the patient was not suicidal and had overall improvement, no delusions, or hallucinations, had full range affect, normal speech, no psychomotor dysfunction, denied suicidal or homicidal ideation, plan, or intent, and had cooperative and calm behavior. Notes reported that the patient did not voice suicidal thoughts, depression, or hopelessness and that the patient was utilizing skill, and was free of urges to harm self, and was making significant progress. 

There were no further reports of severe behavioral symptoms, psychotic symptoms, severe depression, suicidal or homicidal ideation, plan, or intent, or acute medical instability. The patient was not considered an imminent danger to self or others and there was no specific evidence to support that a less restrictive level of care was not feasible. 

The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. The insurer's denial of coverage for a continued inpatient mental health stay is upheld. Medical Necessity is not substantiated.