Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Suicide attempt
Issue under review: Continued inpatient admission

Determination:
The Continued inpatient admission was not medically necessary.

The patient is an adult male. He was admitted with a primary diagnosis of major depressive disorder after he attempted suicide by taking an overdose of 180 0.5 mg clonazepam tablets. He was initially stabilized at another hospital and then transferred to this facility. A secondary diagnosis was PTSD (posttraumatic stress disorder). He had a possible history of alcoholism, but he denied drinking for the last nine years. He had hepatic steatosis, probably secondary to hyperlipidemia. 

At admission, the patient stated that he was disappointed that he failed in his attempt and felt betrayed by God that his attempt was unsuccessful. He has been going through a separation from his wife for three years and stated that he quit his job earlier in the year. He stated that he had the intention of trying to kill himself again if he had the opportunity. He had been seeing his psychiatrist and therapist less and less frequently, as he felt that they did not understand him. The patient's brother reported that the patient had a long history of anhedonia, depression, feelings of hopelessness, and feelings of despair.

The patient was treated with Effexor, Abilify, and ECT (electroconvulsive therapy), which was begun while his medications continued to be titrated. He received a total of 10 ECT treatments while hospitalized, including four treatments after the last authorized date.

A progress summary reported that the patient was alert and verbally responsive. He denied suicidal or homicidal ideation, and no distress was noted. He reported "feeling good." 

A progress note reports that the patient was agreeable to referrals to a partial hospital program. He denied suicidal ideation, was pleasant and cooperative, and stated that he continued to feel that the ECT was helping him. He reported his mood as a 7 out of 10. He noted that his family and others had been very supportive of him and this was helping him as well.

On the first date of service under review, the patient stated, "I feel good and I want to live my life. I would never try to kill myself again." 

The patient was scheduled for his seventh ECT the following day. He planned to stay with his parents for a few weeks after discharge. His affect was brighter. The patient stated, "I am looking forward to going back to work and going on with my life." He rated his mood as 8 out of 10. There was a reference to difficulties with transportation for outpatient ECT. 

Two days later, the treatment plan was for the patient to remain in the hospital for medication and ECT for 11 days and then to be discharged to a partial hospital program.

The patient's mood had improved significantly, and he consistently denied suicidal ideation for at least a week preceding the last authorized date for inpatient care. He cited numerous examples of future orientation. His family was supportive. The only stated rationale for continued inpatient care was transportation difficulties for outpatient ECT. It is not clear if further ECT treatments were indicated, and in any case, no details were provided regarding the stated transportation problems. As noted above, the patient had several supportive family members.

Therefore, given the above, the Continued inpatient admission was not medically necessary.