Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Mental Health. 
Treatment: Mental Health - Inpatient. 

The insurer denied continued inpatient mental health admission. The denial was overturned in whole. 

The patient is a female with history of major depression, anxiety and post-traumatic stress disorder who was initially admitted to the hospital following an overdose. The patient reported that she took an estimate of 20 total tablets of Advil. The patient reported that she cut her forearms bilaterally. Superficial cuts were observed on both arms not needing intervention. The patient has a history of suicide attempts and previous psychiatric hospitalizations. During her hospitalization she was started on Zoloft and trazodone was added to address her insomnia. Her hospitalization was prolonged due to continued self-harm behavior and suicidal gestures. She was noted in the records to threaten to choke herself and was observed to cut and scratch herself several times while on the unit. Her condition would decompensate as discharge dates approached and her family did not feel comfortable taking her home given her history of impulsive and dangerous behaviors. Her psychiatrist felt it was best that she stay in the hospital and transition to a lower level of care once it was safe to do so. The following review is evaluating the medical necessity of continued inpatient mental health admission. 

The health plan's determination is overturned in whole. 

Yes, the requested continued inpatient mental health admission was medically necessary for the patient. The patient is clearly a danger to self and despite the structure of the inpatient setting, she decompensated when stressors were introduced. She continued to engage in and threaten self-harm and has demonstrated a pattern of poor distress tolerance outside of the hospital resulting in significant harm with multiple overdose attempts prior to hospitalization. She was not felt to be safe outside of the hospital and promised to harm herself once discharged per medical documentation. Her psychiatrist deemed that it would be unsafe for patient to be discharged to home. It is well known that individuals with history of trauma are at higher risk of self-harm and patients repeated self-injurious behaviors increase her risk of completed suicide (Hawton et al., 2015).  Olfson et al., 2017 determined that individuals who engage in self-harm have a 37.2 times higher rate of completed suicide than individuals who do not. She voiced intermittent suicidal ideation and demonstrated self-harm behaviors while on the unit. She refused to eat on numerous occasions during her hospitalization and was non adherent with treatment recommendations thus necessitating her level of care. She could not have been safely treated on an outpatient basis as her relationship with her family was one of her biggest stressors/triggers. Her repetitive self-harm behaviors increase her risk of completed suicide and patient's impulsivity, history of trauma, and lack of engagement in treatment supported her continued inpatient stay on the dates in question. 

The health plan's determination of medical necessity is overturned in whole. The patient remained a danger to self during her hospitalization and endorsed suicidal ideation even as discharge to a lower level of care was discussed. She would not have been able to safely be treated at a lower level of care.