Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for inpatient services. The Health Plan has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health condition.Findings: Inpatient psychiatric care is aimed at decompressing the acute exacerbations of episodic serious mental illness.  However, there is no precise, standard algorithm to determine the optimal level of care and length of stay. The standard of care is to perform an initial and serial systematic evaluations to determine the least restrictive environment and appropriate duration of treatment.  The American Psychiatric Association articulates this process in their clinical practice guideline:  The psychiatrist should determine the least restrictive setting for treatment that will be most likely not only to address the patients safety, but also to promote improvement in the patient's condition. The determination of an appropriate setting for treatment should include consideration of the patient's symptom severity, co-occurring psychiatric or general medical conditions, available support system, and level of functioning.  Further, the practice guideline jointly authored by the Department of Veterans Affairs and Department of Defense supports more intensive settings for certain cases:  There is now a fair amount of research that indicates patients with greater substance use severity and co-occurring problems such as psychiatric disorders and housing problems will do better in more intensive forms of treatment.  In this patients case, his alcoholism was central to his daily routine and contributed to significant impairment across multiple domains including health, cognition and social functioning.  The patient recently sustained head trauma that necessitated hospitalization.  His aggressiveness resulted in strained relationships, property damage and a restraining order separating him from his spouse.  The record documented that he was depressed.  On 2/12/18, his antidepressant was increased.  The inpatient team attempted to place the patient in a residential program but his co-occurring cognitive decline introduced a significant dispositional barrier.  Hence, the treating team was faced with a guarded, depressed individual, with addictive illness, cognitive decline, a recent hospitalization for a traumatic intracranial bleed and an unsupportive home environment.  Considering the clinical situation and the absence of a reasonable discharge plan, the attending provider determined that continued inpatient care was medically necessary.  The patients level of functioning, illness burden and available support system were clearly substandard.  It was reasonable to posit that these poorly developed factors more than likely would have undermined patient safety, hindered improvement in his condition, and fueled the need for prompt re-admission in the absence of the hospitalization.  Under such circumstances, a conservative admission was appropriate, safe and consistent with good medical practice. It allowed for additional time to assess the effects of the sertraline dose increase and continue with discharge planning.  Further, the patient remained engaged in active treatment and showed modest improvement until the day of discharge.  In sum, inpatient services were medically necessary for treatment of this patients medical condition.Final Result: The reviewer determined that the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.