Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Depressive symptoms; anxiety
 
Treatment: Continued inpatient mental health treatment

The insurer denied coverage for continued inpatient mental health treatment. The denial is upheld. 

This patient is a female was admitted to inpatient mental health treatment due to worsened depressive symptoms.  She had severely depressed mood, suicidal ideation including wanting to die (though no reported plans), psychomotor retardation, decreased energy and interest, low volume and monotone speech, feelings of hopelessness, poor impulse control, and anxiety.  She was also distraught.  It was reported that she felt guilty related to a mistake at work and had anxiety regarding possibly losing her job.  She had past reported childhood physical and sexual trauma.  She had past psychiatric hospitalizations. She reportedly had past benzodiazepine and Ambien abuse.  Medically, she had a history of hypertension and a pulmonary embolism.  She took Celexa, Remeron, and Trazodone.  She improved and was discharged.

The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Major Depressive Disorders report that 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

As of a specified date 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 she was anxious with elevated blood pressure and heart rate but it was reported that her depressive symptoms continue to improve.  It was reported that she denied suicidal or homicidal ideation, intent, or plan, had okay mood, fair appetite, and was compliant with medications.  Notes reported that she was pleasant, calm, had no suicidal or homicidal ideation or hallucinations.  Notes reported that she was calm, cooperative, had good and stable mood, was well groomed, denied suicidal or homicidal ideation, plan, or intent, or hallucinations, had no deficit in judgment or insight, no behavioral issues, and was at baseline. She reportedly was discharged.  

As of a specified date there were no reports of suicidal or homicidal ideation, intent, or plan, inability to adequately care for basic needs, manic episodes, psychotic symptoms, self-injurious, aggressive, threatening, or agitated behavior.  As of a specified date the chart notes did not indicate that she was an imminent danger to self or others or unable to adequately care for her basic needs.  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.  

Inpatient mental health treatment was not medically necessary.  It appeared that the health care plan acted reasonably and with sound medical judgment and in the best interests of the patient.

The carrier's denial of coverage for the continued inpatient mental health treatment is upheld.  The medical necessity is not substantiated.