Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Depression.
Treatment: Inpatient Mental Health Treatment for Adults with diagnosis code F32.9.
The insurer is denied coverage for Inpatient Mental Health Treatment for Adults with diagnosis code F32.9.
The denial is upheld.
 
This is a female patient who was admitted to inpatient mental health treatment due to depressive symptoms including suicidal ideation with a plan to jump off a train. She has a history of a past suicide attempt and a psychiatric hospitalization. The patient reported having flashbacks and nightmares of past reported sexual abuse victimization. The patient's reported symptoms included sad mood, low energy, and sleeping problems. The patient reportedly took Cymbalta and clonazepam. The patient was discharged.

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. Notes reported that the patient denied suicidal or homicidal ideation, had goal directed thoughts, improved sleep, better mood, was calm and cooperative, and had only mild anxiety. Notes reported that the patient had good sleep, no suicidal ideation, and was feeling more stable overall, had minimal anxiety, and was able to tolerate stressors better, and she was feeling more optimistic about her future. Notes reported that the patient had no aggression, impulsivity, or hopelessness, and denied suicidal or homicidal ideation, hallucinations; the patient reported good sleep and appetite. Notes reported that the patient had okay mood, denied hallucinations, suicidal or homicidal ideation, and had logical and linear thoughts, fair insight and judgment. The patient reportedly was discharged.

According to the American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Major Depressive Disorders, 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.

Based on the review of the medical record the patient had no reports of suicidal or homicidal ideation, intent, or plan, inability to adequately care for basic needs, manic episodes, and psychotic symptoms, self-injurious, aggressive, threatening, or agitated behavior. The chart notes did not provide enough specific evidence that the patient 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. Thus, continued inpatient mental health treatment was not medically necessary.

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

The carrier's denial of coverage for the continued Inpatient Mental Health Treatment for Adults with diagnosis code F32.9 to discharge should be upheld. The medical necessity is not substantiated.