Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Mental Health
Treatment: Inpatient Hospital
The insurer denied the Inpatient Hospital
The denial was upheld


The health plan's determination is upheld in whole. The inpatient hospital stay is not medically necessary. The patient has a past medical history significant for hypertension, aortic valve replacement, traumatic brain injury due to a motor vehicle accident, and benign prostatic hyperplasia  who presented to the hospital because patient was unable to take care of self as well as because of major depression.
The patient reported being in a very sad mood since spouse passed away the previous year after losing a battle to breast cancer. The patient reported a lack of appetite. At the same time, the patient denied any active suicidal ideations. At the time of the initial evaluation the patient was found to be unkempt with soiled pants and dried fecal material. The patient was anhedonic appearing. The head, eyes, ears, neck, throat (HEENT) exam was within normal limits. Lungs were clear to auscultation; the cardiac exam was unremarkable. The abdomen was soft and nontender. There was no lower extremity edema. The patient was alert, and responded to questions appropriately. In the hospital the patient was evaluated by a psychiatrist. According to the consultation note the patient denied any active suicidal or homicidal ideations. At the same time, the psychiatrist concluded that the patient remained at an acutely elevated risk for self-harm due to hopelessness and inability to take care of self. Therefore, the psychiatrist recommended close one on one observation as well as further workup, as mentioned above. During the hospital stay the patient received intravenous fluids for mild dehydration that was associated with mild hypercalcemia and slightly elevated lactic acid level. These laboratory abnormalities resolved pretty quickly. In the hospital the patient continued to be followed by a psychiatrist who recommended inpatient psychiatric treatment after the patient was cleared for discharge by medicine service. 
This patient presented to the hospital with major depression and failure to thrive. However, at the time of the initial evaluation and during the hospital stay, this patient was afebrile and hemodynamically stable, had a normal pulse and respiratory rate.
Patient looked disheveled but the rest of the physical exam did not reveal significant abnormalities. The laboratory evaluation pointed to a mild degree of dehydration without clinically significant electrolyte abnormalities or signs of acute kidney failure. The CT scan of the head did not demonstrate any acute abnormalities. Overall, patient remained in stable clinical condition and did not require any diagnostic studies or procedures necessitating admission at the acute inpatient level of care.
Taking into consideration all of these facts, an admission at a lower level of care was reasonable to rule out any medical condition that could contribute to the patient's symptoms. A lower level of care admission was also indicated since there was a risk of suicide attempt, considering the patient's major depression.
There is no overwhelming evidence that the patient had an unstable medical condition that would justify admission at the acute inpatient level of care. Even though the patient had a risk of suicide, he denied active suicidal ideations to the admitting physician and also to a psychiatrist.
Neither the severity of the patient's condition nor the complexity of the services provided rose to the level of acute inpatient care. Therefore, the admission at a lower level of care was reasonable as a part of the transition to inpatient psychiatric care.