Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Schizoaffective Disorder-Bipolar Type

Treatment: Acute inpatient stay

The insurer denied coverage for acute inpatient stay.

The denial is overturned.

This patient went to the emergency room (ER) due to violent, physically aggressive behavior, severe agitation, property destruction including throwing a television remote at his mother, suicidal ideation and suicidal messages on social media, sleeping problems, and he had noncompliance with medication. He was noted to have tested positive for Novel Coronavirus 2019 (COVID-19) and was admitted to this medical hospital telemetry unit. He had rhabdomyolysis. He was put on 1:1 observation. He was noted to have had a diagnosis of Schizoaffective Disorder-Bipolar Type. He was so agitated that he received intramuscular (IM) Ativan, IM Haldol, IM Thorazine, and IM Benadryl. He also took Depakote. He reportedly had AOT (assisted outpatient treatment) and ACT (assertive community treatment). He had multiple past psychiatric hospitalizations and a significant history of alcohol and cannabis use. He was still physically aggressive and agitated and had threats to harm self, and required 5 point restraints, and also received IM Thorazine and Ativan, and also IM Haldol, intravenous (IV) Ativan and IV Benadryl. He also reportedly refused IV placement after pulling out his IV. He reportedly was transferred to a psychiatric unit for psychiatric treatment.  

It was reported that he had severe physically aggressive and agitated behavior and threats to harm self and required 5 point restraints and multiple IM and IV medications including Haldol, Thorazine, Ativan, and Benadryl. He was considered an imminent danger to self and others and could not be treated in a less restrictive level of care other than an acute hospital. He reportedly had COVID-19 positive test and rhabdomyolysis and there were efforts to hospitalize him and he was transferred to a psychiatric unit. 

The Milliman Care Guidelines (MCG) Behavioral Health Inpatient Level of Care Adult-Geriatric criteria reports that a patient meets criteria for inpatient behavioral health level of care if they present as an imminent danger to self or others, have severe psychiatric or behavioral symptoms, have a severely dysfunctional life including inability to care for self, are unwilling to participate voluntarily, or if a less restrictive level of care is not feasible. 

In this case, this patient had reports of severe psychiatric symptoms including physically aggressive and agitated behavior and threats to harm self. The patient required 5 point restraints and also received IM Thorazine, IM Ativan, IM Haldol, IV Ativan and IV Benadryl. He had an inability to function and care for his basic needs and required hospital treatment until transfer to the psychiatric unit. Notes on admission reported that he had violent, physically aggressive behavior, severe agitation, property destruction including throwing a television remote at his mother, suicidal ideation and suicidal messages on social media, sleeping problems, and he had noncompliance with medication and also tested positive for COVID-19. He was considered an imminent danger to self and others and in need of 24 hour inpatient hospital treatment. 

Notes reported that he was agitated and removed IV access and refused IV placement and required IM Haldol. He continued to present as an imminent danger to self and others and required 24 hour hospital treatment still. He reportedly was transferred to a psychiatric unit for psychiatric treatment, as he was still considered an imminent danger to self and others and required inpatient hospital treatment. This patient had severe psychiatric symptoms, including severe behavioral symptoms and threats to harm self and others that required 5 point restraints and multiple IV and IM medications. 

It did not appear that the health care plan acted reasonably, with sound medical judgment, or in the best interests of the patient.

The insurer's denial of coverage for the acute inpatient stay is reversed. Medical necessity is substantiated.