Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Severe Depression, Suicidal Ideation

Treatment: continued inpatient behavioral health hospital services

The insurer denied coverage for continued inpatient behavioral health hospital services.

The denial is modified.

This is a female patient who was admitted for inpatient behavioral health treatment due to severe depressive symptoms including depressed mood, hopelessness and helplessness, suicidal thoughts of wanting to die, and she reportedly overdosed on pills the night prior to admission as she reported that she was tired of living. The patient had multiple medical problems. The patient had been drinking alcohol excessively also. The patient was admitted and was treated with Ativan and Librium protocol. The patient's medication regimen was also adjusted to target and treat her depressive symptoms. The patient was stabilized and was discharged one month later.

The American Psychiatry Association (APA) Practice Guidelines for the Treatment of Patients with Suicidal Behaviors reports that patients with suicide attempts are at high risk for suicide as past suicide attempts are the single most reliable predictor of suicide. The APA Practice Guidelines for the Treatment of Patients with Suicidal Behaviors also reports that patients with feelings of hopelessness, major depressive episodes, substance/alcohol use are at higher risk for suicide and she had severe depressive symptoms, hopelessness, and was drinking excessively, and had a suicide attempt the night prior to admission so she was considered a high risk for suicide. It also 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 and that observation in the hospital is appropriate to better ensure their safety. 

This patient was considered a high risk patient and benefitted from remaining in the hospital and being observed and assessed for safety until day 24 of admission as the chart notes reported continued severe depressive symptoms until then but not as of the days to follow. Notes up to day 24 of admission reported that she had days of depressed and irritable mood, hopelessness and helplessness. She continued to report severe depressive symptoms until then and had medication changes so she required continued hospitalization. However, after day 25 of admission, the chart notes reported that the patient was more motivated, less anxious, had brighter affect, and was compliant with medication. The patient denied suicidal ideation, and was compliant. As of day 25 of admission, the chart notes did not report severe depressive symptoms for the patient, and provided no support that the patient only required 24-hour hospital treatment then. Also, there were no reports of specific identifiable treatment goals or objectives that could only be achieved in this 24-hour hospital treatment or that could not be achieved in a less restrictive setting as of day 24 of admission. Thus, while inpatient behavioral health treatment up to day 24 of admission was medically necessary, the continued inpatient behavioral health treatment thereafter was not medically necessary. 

Based on the above, the medical necessity for inpatient behavioral health hospital services up to day 24 of admission is substantiated and the medical necessity for inpatient behavioral health hospital services thereafter is not substantiated. The insurer's denial should be modified. Approve up to day 24 of admission. Deny the subsequent dates.