Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Schizoaffective disorder
Treatment: Inpatient Mental Health Stay
The insurer denied the Inpatient Mental Health Stay
The determination is overturned.

The patient has diagnoses of  schizoaffective disorder, depressed type and co-occurring substance use disorder (tobacco and alcohol). He was admitted to acute inpatient level services with severe symptoms of depression and suicidal ideation with plans to hang or shoot himself. The patient's admission had been precipitated by the worsening symptoms of depression with nonadherence with his medication and increasing use of alcohol with onset of suicidality.
The patient has a history of multiple prior admissions for psychiatric treatment for schizoaffective disorder and/or major depressive disorder with suicidal behavior, and had been in outpatient treatment with non-compliance with treatment in the community.
There were no acute general medical issues in this case, and laboratory assessments, a chest x-ray and an electrocardiogram (EKG) were normal or unremarkable with a negative drug screen consistent with his history. There was evidence of malnutrition or anemia with a low hemoglobin.
The patient is single, unemployed, and homeless living in a men's shelter. There was no mention of trauma history or legal issues in this case. He had two children that he had not seen in seven years which was a prominent clinical feature of his depression. He had no social supports.
On Mental Status Examination on admission, the patient was motor retarded, guarded with poor eye contact, and dysphoric mood and flat affect. He displayed depressed mood with slowed mentation with thought blocking. He had decreased concentration, energy, appetite, sleep, and volition. His speech was coherent with mental confusion and disorganized thought processing and morbid thought content with hopelessness, helplessness, worthlessness and suicidality. Insight and judgment were limited and impaired.
The patient was admitted to acute inpatient level care after medical screening in the emergency department. The patient's treatment plan included safety-monitoring, access to group and milieu therapies, and resumption of medication to address mood disturbance and the thought disorder. He had the availability of nicotine and vitamin replacement therapy. The patient was initially depressed and socially withdrawn. However, he was increasingly cooperative with staff and became medication adherent with use of Depakote, Prozac and Abilify, titrated as clinically appropriate. The patient tended to isolate with minimal participation in the therapeutic activities. His depression and thought disorder persisted, and he remained anxious and depressed requiring as needed (PRN) medication for anxiety and agitation. The patient remained restless, motor agitated and anxious with irritable dysphoria and labile affect requiring ongoing re-direction from staff and safety monitoring. His thoughts were disorganized with persistent depressive ruminations focused on his children. He had not had significant withdrawal symptoms and was not interested in referral for rehabilitation treatment of the alcohol use disorder or smoking cessation.
The patient was noted to exhibit improving mood and diminished anxiety. He was increasingly better with his functioning including less resistance to returning to his shelter.
A discharge plan was completed including plans for after care and return to the community. At the time of discharge, the patient was better focused, calmer, and displaying better judgment with improved mood and brighter affect without evidence for suicidal intent or plan. Discharge occurred with clinically appropriate aftercare in collaboration with community providers to include mental health services with a safety plan, as well as recommendations to address the co-occurring substance use disorders with tobacco and alcohol.
The health plan documents including case notes and criteria  and appeal documents were reviewed, as well as correspondence from the health plan and the treatment facility. The dates under review were denied certification of coverage by the health plan for continued inpatient level treatment on the basis of medical necessity. This case is a New York mandated review.
The issue under review is continued inpatient mental health stay.
The requested health service/treatment of the continued inpatient mental health stay is medically necessary for this patient.
The patient's symptoms of mood and thought disorder together with continued risk of impulsive behavior and suicidal risk prompted the necessity for continue acute inpatient level structure and monitoring through discharge. The case is complicated by active substance use and non-compliance with treatment and medication adherence problems in the context of alcohol use and a history of suicidal behavior. The residual symptoms of mood disorder and thought disorder; risk for suicidal behavior and non-compliance, co-occurring substance use disorder, and treatment issues related to arranging a safe and appropriate discharge plan warranted the continued services at an acute inpatient level of care to include safety monitoring and maintaining abstinence from alcohol. The inpatient continued stay through discharge was therefore clinically appropriate and medical necessary for continued inpatient level structure and 24-hour monitoring through the day of discharge, when the patient had reached a level of stability that he could return to the community shelter with clinically appropriate follow-up and aftercare.