Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Mental Health. 
Treatment: Mental Health Inpatient. 

The insurer denied the acute inpatient psychiatric admission. The denial is upheld in whole. 

The patient is a male with longstanding mood disorder best characterized as bipolar disorder. The patient was referred by his outpatient psychiatrist for inpatient psychiatric services due to worsening depression and suicidal ideation. The symptoms of depression had occurred in the context of a relapse and substance use disorder with alcohol and cannabis (marijuana) use, and multiple psychosocial stressors including the relapse and his leave from work four months prior to his admission. He was using up to six beers four to six days per week with intermittent use of marijuana. His worsening depression included a profound sense of hopelessness and low energy with hypersomnia, sleeping up to 12 hours per day. Additionally, he had weaned himself off of lithium due to adverse effects-nausea and gastrointestinal upset. 

By the date of service under review, the patient had consistently denied suicidal ideation and was committed to resuming involvement with 12-step recovery groups. His family was supportive and were involved in the development of a discharge plan for step down to Partial Hospitalization Program (PHP) level care. His discharge was delayed, as his parents were traveling, but he continued inpatient level treatment from the date of service under review forward and remained pleasant with diminishing symptoms of anxiety and depression throughout the remainder of his stay. Mental status examination revealed no safety concerns, fair insight and judgment, and clear speech and thought processing as well as improved mood and hope about the future. Medications were continued with tolerability, as noted above. The patient was discharged with recommendations for follow-up care with his psychiatrist and plans to start partial hospital program services. The subject under review is the medical necessity for the acute inpatient psychiatric admission. 

The health plan's determination is upheld in whole. 

No, requested health service/treatment of Acute Inpatient Psychiatric Admission, Continued Acute Inpatient Mental Health Services is not medically necessary for this patient. 

From the date of service under review going forward, the patient did not show the continued presence of severe symptoms that would have required continued acute inpatient level care. The patient denied any intent of suicide and did not show aggressive impulses. The patient's motivation to participate in treatment and insight and judgment had improved or remained fair. The influence of psychosocial stressors were not so severe, to interfere with continued treatment at a lower level of care, and there were no complications related to the co-occurring substance use disorder or related to general medical problems that would prevent continued treatment in a less restrictive setting. Moreover, medications had been adjusted and were tolerated with good response. Thus, medical necessity is not met. This answer is consistent NY State Office of Alcoholism and Substance Abuse Services (OASAS) Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) 3/0 Criteria pertaining to the co-occurring substance use disorders in this patient.