Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Schizophrenia
Treatment:  Mental Health Inpatient

The case involves an adult admitted to acute inpatient psychiatric services for an exacerbation of a chronic psychotic disorder best characterized as schizophrenia, unspecified type.  The patient had shown increasing symptoms of psychosis following discontinuation of his medication, olanzapine and Depakote.  Patient deteriorated over a three week time frame with onset of aggressive behavior with threats toward family and destruction of home property.  Patient had a history of increasing levels of aggression over a five year period and had been diagnosed with schizophrenia at age 18 when there was a change in his behavior.  His presentation with emergency medical services included bizarre and erratic behavior, disorganized and delusional thoughts with paranoid thinking together with motor agitation, and increasing responses to internal stimuli.  Patient was brought to the emergency department, and was subsequently admitted after medical clearance that included physical examination, laboratory assessment and drug screen.  The assessment included no abnormal or remarkable laboratory findings including a negative drug screen consistent with history.  Mental Status Examination on admission:  The patient was psychotic and cognitively impaired with thought blocking, laconic speech, and response to internal stimuli.  Patient was uncooperative and guarded with poor eye contact.  Patient displayed motor agitation with irritable mood. Insight was limited and judgment impaired.  Patient demonstrated poor attention and concentration due to the internal stimuli and disorganized thought patterns with tangential thought production that was illogical and incoherent with frequent bouts of talking to self or responding to internal stimuli.  The patient's treatment plan included safety monitoring and medication targeting mood disturbance and psychosis, as well as the opportunity for therapy and psycho-education provided in the therapeutic milieu.  The patient was uncooperative initially, but gradually became more cooperative with treatment.  The Health plan's determination of medical necessity is overturned in whole.  The patient had severe symptoms with an acute exacerbation of schizophrenia associated with disorganized thought patterns and responses to internal stimuli that were associated with erratic and problematic behavior.  The case was complicated by medication changes with subsequent onset of aggressive behavior and decline in functioning.  The patient had deteriorated to the point that he was a safety risk, and, outpatient treatment had failed to prevent a relapse precipitated by medication changes.  During the time interval under review, the patient remained at risk for aggressive behavior and required continued inpatient structure and monitoring while receiving active treatment.  The patient could not have been safely or effectively managed during the time interval under review at a lower level of care or in a less restrictive treatment setting.  The patient's severity of symptoms and risk for continued aggressive behavior and safety issues related to persistent symptoms of psychosis together with the co-morbid autism spectrum disorder with intellectual deficiency, were clinical factors and treatment dimensions that warranted the continued acute inpatient hospital care, structure, and monitoring as proposed through discharge.  The medication adjustments and safety monitoring together with attention to the compliance issues in this case were medically necessary in this case scenario; the intensity of services and safety issues related to erratic/aggressive behavior and affective instability could not have been effectively addressed or managed at a lower level of care during the time interval under review.