Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Mental Health/depression
Treatment: Mental health inpatient
The insurer denied the Mental health impatient stay. The denial was overturned.

This case involves a patient admitted for acute inpatient psychiatric treatment. The patient had become increasingly anxious and depressed with suicidal ideation, plan and intent in the context of psychosocial stressors that included primary support and occupational, housing and social environment domains. the patient had reconnected with an ex-boyfriend despite a history of physical and emotional abuse.  the patient had cut off communication with a daughter and had lost job three weeks prior to presentation. Patient was kicked out of the boyfriends housing after an argument and was wandering the streets barefoot, intoxicated and crying. Patient was brought to the emergency department by Emergency Medical Services (EMS) which resulted in evaluation and admission for inpatient level psychiatric treatment.
At the time of  admission, the patient had a blood alcohol level of 308 and  was noted to be severely depressed with persistent suicidal ideation wanting to die from carbon monoxide poisoning. Functioning had deteriorated with social isolation and an increase in drinking with up to one gallon of vodka per day and intermittent use of cocaine. the patient underwent medical screening with the admission for acute inpatient psychiatric evaluation and treatment and safety monitoring. Patient had a history of mood disorder best characterized as recurrent and severe major depressive disorder without psychotic features and severe symptoms of anxiety and panic attacks. The patient was previously involved in outpatient treatment with medication and therapy services, but had not followed up and had been non-adherent with past treatment with Zoloft and Effexor and Abilify.
The patient's mental status examination revealed a depressed mood with hopelessness, helplessness, anhedonia, and morbid thought content that included thoughts of death and suicidal ideation wanting to die from carbon monoxide poisoning.  Sleep, appetite, energy levels, concentration, and volition were disturbed. Insight and judgment were limited due to the severity of depression and associated symptoms of anxiety and alcohol dependence. There was active substance use disorder with alcohol, tobacco and cocaine with a drug screen positive for cocaine. The patient was admitted to acute inpatient level services and maintained on close observation with structured milieu therapy, and pharmacotherapy with antidepressant and anxiolytic medication supplemented with medication to enhance sleep and address anxiety. Patient was placed on a Clinical Institute Withdrawal Assessment (CIWA) protocol with Ativan and received vitamin and nicotine replacement therapy. The psychotropic regimen included Remeron, titrated as clinically appropriate with the availability of as needed (prn) medications for anxiety and insomnia. Group and individual psychotherapy were provided as well as other therapeutic interventions to facilitate better coping and functioning and reality testing. The post-acute withdrawal symptoms from alcohol gradually diminished without complications. The team was working on a discharge plan to include a clinically appropriate step down and safety plan in view of the patient's history of non-adherence and history of quickly decompensating with past treatment episodes. the patient had improved and no longer had a plan or intent of suicide. Patient was more actively participating in therapeutic activities. Medications were tolerated with improved mood and diminished anxiety; and, the patient was adherent with medications and compliant with treatment plan. The daughter participated in a discharge planning meeting on the day of discharge in order to plan for a safe and clinically appropriate disposition. The health plan determination of medical necessity is overturned in whole.
The patient's Continued Psychiatric Acute Inpatient Level of was clinically appropriate, reasonable, and in the best interest of the patient. The patient had severe symptoms of depression,  was a safety risk, and, outpatient treatment had failed to prevent the worsening symptoms of depression with onset of severe symptoms in the context of a potential for a lethal suicide attempt with alcohol and cocaine use, and with deterioration in functioning. The patient remained a safety risk and functionally impaired with high risk for relapse if discharged from acute inpatient level care prior and, the patient needed to reach a stable baseline of functioning with assurance of medication tolerability with a solid disposition and safety plan prior to discharge from inpatient level care.
Thus, it was medically necessary for this patient with severe and recurrent major depressive disorder to remain in the acute inpatient setting.