Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Schizophrenia

Treatment: Inpatient Admission 

The insurer denied the inpatient admission. The denial was upheld. 

This is a male patient with a history of Schizophrenia. It was reported that the patient had been previously hospitalized for mental health treatment. He presented to a behavioral health hospital with symptoms of auditory hallucinations, responding to internal stimuli, disorganization and confusion, paranoid delusional thinking, depressed mood, suicidal thoughts. It was noted that the patient had poor activities of daily living (ADLs). The patient was admitted to the hospital with a plan to change his current medication regimen. He attended therapy and was started on Risperdal twice a day and Trazadone at night. It was reported that the patient's symptoms had improved and he was compliant with his medication administration. The patient was discharged to another facility.

The American Psychiatric Association Practice Guidelines for the Treatment of Patients with Schizophrenia reports that patients with hallucinations, delusional thinking, disorganized behavior, suicidal or homicidal plan or intent, agitation, or aggressive behavior are candidates for inpatient treatment. In this case, there were no reports of further serious psychotic symptoms such as delusions, hallucinations, or disorganized behavior, suicidal or homicidal ideation, intent, or plan, manic symptoms, aggressive, threatening, self-injurious, or agitated behavior, withdrawal symptoms or acute medical instability for this patient. Notes dated from the later part of his admission reported that the patient had no psychotic symptoms and no thoughts to harm himself. Further notes reported that the patient had no psychotic symptoms and no thoughts to harm himself, and the patient reportedly showered. Notes from several days prior to his discharge reported that the patient had no psychotic symptoms and no thoughts to harm himself, and that the patient was social, pleasant, and was interacting with others well. Further notes reported that the patient had fair mood, good appetite, and was compliant to taking his medication, and was not clinically depressed. It also reported that the patient had no psychotic symptoms and no thoughts to harm himself. In addition it was reported that the patient had no psychotic symptoms and no thoughts to harm himself, and that the patient had a good mood. Notes from the day of discharge reported that the patient was discharged to the another facility. In the middle of the patient's admission there were no reports of acute or severe mental health or behavioral symptoms that required 24-hour acute hospital treatment, and there were no reports of specific identifiable or quantifiable treatment goals or objectives that could only be achieved in a 24-hour acute psychiatric hospital treatment setting as of then or that could not be achieved in a less restrictive level of care as of then. The health plan acted reasonably with sound medical judgment and in the best interest of the patient.

The carrier denial of coverage for the continued inpatient hospital admission is upheld.  The medical necessity is not substantiated.