Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Trauma/Injuries-suicide.
Treatment: Inpatient Hospital. 
The insurer denied inpatient stay. 
The denial is overturned. 

The patient is a female with history of previous suicide attempts in the past who presented with complaints of nausea, vomiting and mid epigastric pain for 1 hour. She states that she took about 10 pills of Motrin 600 milligrams (mg). The patient states that she was upset that her boyfriend broke up with her yesterday and she lives with him therefore she took "a half of handful of Motrin 600mg" at around 12 pm. She tried to sleep it off and woke up around 2pm with cramping abdominal pain in all quadrants and had one episode of non-bloody non-bilious (NBNB) emesis. She was taken to the hospital by her ex-boyfriend.

The patient was admitted for intentional drug overdose for suicide attempt. She was started on intravenous (IV) Pepcid twice daily (BID), intravenous (IV) Zofran for nausea and vomiting. Started nothing by mouth (NPO) and advance diet as tolerated after nausea and vomiting controlled. 1:1 observation for suicide attempt until cleared by psychiatry. Psychiatry evaluated patient and confirmed need for 1:1 for suicide precautions for impulsive, high-risk behavior. No psychiatric medications were started. The patient remained clinically and hemodynamically stable with improved labs. On psych follow up the following day patient deemed not imminent danger to self or others and did not warrant any acute psychiatric interventions. The patient diagnosed with adjustment disorder with depressed mood, rule out (r/o) personality disorder and post-traumatic stress disorder (PTSD). The patient to follow up with psychiatry outpatient for psychotherapy. Patient was psychiatrically cleared for discharge. The patient instructed to follow up with primary medical doctor (PMD) in 5 days and with psychiatry as outpatient. The subject under review is the medical necessity of the inpatient stay.

The health plan's determination is overturned.

The requested inpatient stay is medically necessary for this patient. This patient presented after suicide attempt following ingestion of approximately 10 tablets of 600 mg of ibuprofen. She was symptomatic at the time of presentation with abdominal pain and nausea. She was evaluated by psychiatry and they felt she was an imminent danger to herself and warranted acute psychiatric hospitalization for stabilization and treatment. Milliman Care Guidelines notes for Behavioral Health General Recovery Guidelines (GRG) document inpatient admission is indicated for imminent danger to self or to others. Based on the Milliman Care Guidelines for Drug Ingestion or Overdose, inpatient admission is indicated for a significant finding or clinical condition judged too severe or too persistent to be within the scope of observation care including psychiatric risk status not acceptable for outpatient management. On initial mental status exam this patient's mood was anxious, affect blunted with limited judgment and limited impulse control. To safely care for this patient until final disposition determined by psychiatry team, inpatient care with 1:1 is medically necessary and in the best interest of the patient. This patient must be carefully monitored 24 hours a day for recurrence of suicidal and/or aggressive behaviors. Inpatient care is the standard for pediatric patients with active and current suicidal behaviors. For these reasons, the patient's admission was medically necessary and appropriate for inpatient level of care.