Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Major Depressive Disorder
Treatment: Inpatient admission 
The insurer denied coverage for an inpatient admission 
The denial is overturned

This female reportedly was admitted to this inpatient hospital after an intentional overdose of 15 Venlafaxine pills in a suicide attempt. She reportedly had suicidal thoughts and did not want to live anymore, had sad mood, feelings of hopelessness and helplessness, noncompliance with medications, and had significantly increased stress with her family, school, and financially as she was unemployed. It was reported that she had a diagnosis of Major Depressive Disorder. She reportedly was admitted to the PICU (pediatric intensive care unit) with cardiac telemetry as her heart rate was elevated at 106. She reportedly was seen by the psychiatric consultant, and she was on 1:1 observation for safety. Poison control reportedly recommended ECG (electrocardiogram), cardiac monitoring, and lab studies, and IV (intravenous) fluids for hydration. 

The reviewer disagrees with the decision to deny coverage for inpatient hospital treatment and the medical records provided enough specific evidence to support that she required this level of care then. The MCG (Milliman Care Guidelines) Drug Ingestion or Overdose criteria reports that one meets criteria if one of the following are met: hemodynamic instability, dangerous arrhythmia, respiratory abnormalities, hypertension requiring inpatient treatment, specific finding indicating severe and prolonged drug toxicity, or inpatient admission is required other than observation care. Also, the APA Practice Guidelines for the Treatment of Patients with Suicidal Behaviors reports that patients with suicide attempts are at high risk of suicide. Suicide attempts are the single most reliable predictor of suicide. This patient was considered an imminent danger to self-due to an intentional overdose of Venlafaxine in a suicide attempt and had major depressive symptoms including suicidal thoughts and reports of not wanting to live anymore, sad mood, feelings of hopelessness and helplessness, noncompliance with medications, and she had significantly increased stress with her family, school, and financially. She was on 1:1 observation for suicide watch and for safety. She had a diagnosis of Major Depressive Disorder. She also had tachycardia of 106 due to the overdose. Also, the APA Practice Guidelines for the Treatment of Patients with Suicidal Behaviors reports that patients may require more time in the hospital to better assess suicide because they sometimes do not tell the truth regarding their suicidal thoughts in order to leave the hospital and that observation in the hospital is appropriate to better ensure their safety. This patient was considered a high-risk patient due to a suicide attempt in which she intentional had an overdose of her antidepressant medication so she was considered an imminent danger to self and in need of inpatient hospital treatment. Even though she was not in an acute psychiatric hospital, she still required 24-hour inpatient hospital treatment due to her suicide attempt as she had 1:1 observation and psychiatric consultation while in this medical setting. As a result, the recommendation is to overturn the previous decision and approve coverage for inpatient hospital treatment. 

The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for hospital admission is overturned. Medical Necessity is substantiated.