Appeal type: Medical necessity
Decision: Overturned

The patient is an adult  with schizoaffective disorder, depressed type and co-occurring substance use disorder (cocaine, cannabis and alcohol). Patient was admitted to acute inpatient level services with severe symptoms of depression, suicidal ideation, psychosis with delusions and morbid preoccupations, command auditory hallucinations telling patient to harm self or others, and motor agitation. The patient's admission had been precipitated by worsening depression with suicidal ideation and psychosis in the context of severe substance use disorder and non-compliance with his mental health treatment. Patient was using up to three pints of vodka in a day together with 10-15 blunts of marijuana mixed with cocaine;  also tobacco dependent at 14 pack per day. Patient had stopped  medication, risperidone, at an unknown dose. The patient endorsed symptoms of depression with the command auditory hallucinations, reports of visual hallucinations (seeing shadowy figures) and paranoid thinking that patient was being followed and that thoughts were being controlled; Patient was erratic in behavior and superficially cooperative at the time of presentation in the context of drug and alcohol use with the large quantities of cannabis and alcohol. The patient had been non-adherent with medications and non-compliant with outpatient treatment in the context of active substance abuse with alcohol, cocaine and cannabis, as well as use of tobacco. The patient is homeless living on the street and in shelters, unemployed, and has limited or no social supports. The patient was admitted to acute inpatient level care on after medical screening in the emergency department. The patient's treatment plan included safety-monitoring, access to group and milieu therapies, and resumption of medications with an initial dose of risperidone at one milligrams (mg) twice daily, titrated as clinically appropriate. He received vitamin replacement therapy and as needed (prn) medications to address withdrawal from alcohol or nicotine. The patient was initially depressed, paranoid, and socially withdrawn. However after several days, was increasingly cooperative with staff and became medication adherent;  tended to isolate with social withdrawal and minimal participation in the therapeutic activities during the first week of his inpatient stay. The patient's delusions/morbid preoccupations and hallucinations persisted, and patient remained dysphoric with motor agitation and labile affect addressed with safety monitoring and prn medications while risperidone was titrated to three mg twice daily together with Cogentin. a discharge plan was completed including plans for after care and return to the community with housing/shelter. At the time of discharge the patient was better focused, calmer, and displaying better judgment with improved mood and brighter affect. Inpatient Mental Health Treatment is medically necessary for this patient. The admission and the continued inpatient stay for the dates of service  could not have been safely or effectively provided at a lower level of care. The patient's symptoms of psychosis and mood disorder together with continued risk of impulsive behavior and suicidal risk prompted the necessity for the admission and the continued acute inpatient level structure and monitoring provided through discharge. The case is complicated by active substance use disorders; and non-compliance with treatment and medication adherence problems in the context of severe psychosocial stressors. . Medically necessary treatment included safety monitoring and maintaining abstinence from substances of abuse while titrating medications and initiating a long-acting injectable antipsychotic medication that was critical to the patient's treatment in the context of past non-compliance with medication treatment with oral medications. The HP determination of medical necessity is overturned in whole.