Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Schizoaffective Disorder. 
Treatment: Continued admission at an inpatient mental health. 

The insurer denied coverage for continued admission at an inpatient mental health. 

The denial is overturned. 

This is a female that was admitted to inpatient mental health hospital due to psychotic and mood symptoms including auditory hallucinations cursing at her, paranoid delusional thinking, suicidal ideation with a plan to overdose. She had a diagnosis of Schizoaffective Disorder. She took Prolixin, Gabapentin, and Klonopin. She was scheduled for discharge but was too fearful to return home to her roommate who she stated was throwing objects at her prior to admission. She had the Assertive Community Treatment (ACT) team and social work set up respite housing which was available on the next day so she was discharge. 

The InterQual 2019 Behavioral Health-Adult and Geriatric Psychiatry-Inpatient medical necessity criteria reports that if one has assaultive behavior within 24 hours, catatonia, command hallucinations to harm self or others, destruction of property with poor impulse control within 24 hours, disorganized behavior, unstable eating disorder, fire setting, homicidal or suicidal attempt within 24 hours, suicidal or  homicidal ideation with high risk for an attempt, mania, risk of harm to self or others, non-suicidal self-injury and continued danger to self, positive psychotic symptoms with risk of harm to self or others, posttraumatic stress disorder (PTSD) with risk of harm to self or others, psychomotor agitation and potential for violence, severe social withdrawal and refusing treatment, unavailable support or inability to provide needed care and supervision and there is acute deterioration in functioning then meet criteria for inpatient treatment. Also, if symptoms improved but the patient was not clinically stable for discharge or was a high risk for re-hospitalization or a high risk of harm to self or others then criteria would have still been met. 

The American Psychiatric Association Practice Guidelines for the Treatment of Patients with Schizophrenia reports that patients with hallucinations, delusional thinking, disorganized thinking or behavior, severe agitation, aggression, or inability to care for basic needs are in need of hospital treatment. 

In this case, the chart notes did report that she had the continued delusion regarding her roommate hurting her and was too anxious to be discharged to the housing that the roommate lived at so she was too at risk to decompensate with her psychotic symptoms and also care for her basic needs if discharged there. She could not safely be treated outside this hospital without appropriate housing which did not occur until the next day as it was reported that the ACT team and social work arranged for respite housing. She continued to require psychiatric hospital treatment until. 

Coverage for inpatient mental health treatment at this hospital was medically necessary. It did not appear that the health care plan acted in the best interests of the patient. 

The insurer's denial of coverage for the continued admission at an inpatient mental health level of care reversed. Medical necessity is substantiated.