Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Schizophrenia and bipolar disorder 
Treatment: Continued inpatient admission
The insurer denied continued inpatient admission.
The denial is upheld.
The proposed continued inpatient admission was not medically necessary.
This was one of the multiple psychiatric admissions for this male with diagnoses of schizophrenia and bipolar disorder who was brought to the hospital by ambulance due to allegedly aggressive behavior in the context of medication noncompliance.  
The patient was unemployed. 
The patient's outpatient social worker noted that he appeared disorganized and internally preoccupied, talking to himself in a senseless way. She saw him the following day and described him as uncooperative and unable to have a conversation. The patient's grandmother, with whom he lived, reported that he had been aggressive to her, but no details are provided.
During the evaluation in the emergency department, the patient stated that there was nothing wrong with him. He reported that he did not know why he was brought to the hospital. He was guarded and uncooperative. As per his mother and sister in law, the patient had been noncompliant with his monthly intramuscular (IM) and oral medications. He was accompanied to the hospital by his ACT program doctor. The grandmother stated he had been irritable since he stopped taking his medications and that she did not feel safe with him if he did not take his medications.
Upon admission the patient was described as being irritable, anxious, and uncooperative, with loud, pressured speech. He had no insight and denied any mental problems stating that he did not need medications. He had racing thoughts, poor judgment, poor impulse control, flat affect, and unkempt appearance. He nevertheless sat quietly in the emergency room. He felt nervous and was given Ativan orally. He denied suicidal or homicidal ideation and denied hallucinations.
The patient was maintained on risperidone, Depakote, Cogentin, IM Risperdal Consta, and various somatic medications. 
Progress notes report that the patient was calm, cooperative and compliant with medications. He denied auditory or visual hallucinations and denied suicidal and homicidal ideation. He continued to have some thought blocking and thought disorganization. He had received 25 milligrams (mg) of Risperdal Consta. He was isolative and preferred to stay in his bed. 
The patient was calm and reported feeling OK. He denied any perceptual disturbances. He took all his medications with no side effects. He showed improvement exhibited by increased ability to share and engage in a discussion group. He was able to discuss the reasons for taking his medication and identify positive coping skills. Overall, he was described as calm, pleasant, and less disorganized than previously. 
The patient continued to improve in all parameters and was discharged to the care of the ACT program.
The only rationale provided in the appeal letter for continued acute inpatient care is that the patient remained socially isolated and psychologically disorganized. These symptoms are chronic and consistent with the patient's diagnosis. Notes during the period in question show steady improvement. There were no behavioral outbursts at any time. There was no suicidal or homicidal ideation. The patient was compliant with his medications.
There is no documented history of danger to self or others. The patient accepted long acting depot medications, in addition to his daily antipsychotic medications, while in the hospital. The patient had intensive outpatient follow up by an ACT psychiatrist and social worker. The chronic, relatively minor thought disordered problems described could have been addressed safely and equally effectively by the ACT program in a less intensive community treatment setting. Nothing in the documentation provided suggests that the patient required 24-hour daily confinement.