Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Abuse/Addiction. 
Treatment: Substance Abuse Inpatient. 
The insurer denied mental health services. 
The denial is overturned.

The patient is a male admitted for acute inpatient psychiatric treatment. The patient was brought to the emergency department by emergency medical services with dizziness and fear of passing out in the context of heavy cocaine use and comorbid alcohol use disorder. The patient endorsed symptoms of depression with bizarre thought content with auditory hallucinations together with suicidal ideation with plan to cut his wrists. Diagnoses included mood disorder of the depressed type and co-occurring cocaine (crack) and alcohol use disorders with active substance use. The patient referenced the escalating substance use and severe psychosocial stressors as precipitating and perpetuating factors including stress within primary support, financial, housing and occupational domains.

The patient was admitted to acute inpatient level services and maintained on close observation with structured milieu therapy, and pharmacotherapy with antidepressant and anxiolytic medication supplemented with medication to enhance sleep and address anxiety. His psychotropic regimen included Lexapro, risperidone and trazodone with availability of as needed (prn) medications for anxiety. Group and individual psychotherapy were available, as well as other therapeutic interventions to facilitate better coping and functioning and reality testing.

The patient improved and no longer had a plan or intent of suicide. Medications were tolerated with improved mood and diminished anxiety. He participated in a discharge planning meeting in order to achieve a safe and clinically appropriate disposition. Discharge plans were made to include referral for inpatient level rehabilitation treatment and continued therapy and medication management with a safety plan. On the day of discharge, the patient had improved sleep and appetite, and was deemed to be lower risk for suicide with no evidence for psychosis or general medical instability. He was discharged with immediate transfer for substance use disorder rehabilitation treatment.
The subject under review is the medical necessity for the mental health services.

The care the patient received could not have been safely or effectively provided with lower-level care in this case scenario in the context of a severe mood disorder, co-occurring substance use disorders, and severe psychosocial stressors with high risk for suicidal behavior. During the time interval under review, the patient continued to display acute symptoms related to the mood disorder that warranted continued inpatient level structure and monitoring, as well as efforts to develop a safe and clinically appropriate discharge plan and disposition. The continued inpatient level care through discharge was reasonable in this case scenario and in the best interest of the patient reflecting sound medical judgment with regard to safety issues in this case and risk for relapse including the use of substances of abuse. The health plan denial is not reasonable in this case scenario in view of the clinical features, treatment dimensions and suicide risk. These answers are consistent with prevailing standards of professional practice, the scientific literature, and published practice guidelines, as well as the application of NY State Office of Alcoholism and Substance Abuse Services (OASAS) Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) 3.0 Guidelines, referenced below.