Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Mental Health - Psychosis 
Treatment: Mental Health: Inpatient 

This case involves a female admitted from the emergency department for acute inpatient psychiatric treatment. The patient was brought in by police due to erratic behavior and aggressive behavior in the context of psychosis and mood disturbance. She has a history of bipolar disorder and co-occurring substance use disorder with use of alcohol and cannabis and tobacco. She was acutely agitated and paranoid and had stopped her psychotropic medications. 

The patient has a history of mood disorder best characterized as bipolar disorder, but a past diagnosis of schizoaffective disorder, bipolar type. She was receiving outpatient psychiatric treatment with medications but had been non-compliant with treatment and was actively using substances of abuse, as noted. There was a history of multiple past psychiatric hospitalizations. 

The mental status examination revealed a disheveled and poorly groomed female with labile affect and anxiety including apprehension, nervousness, tension, irritability, and excessive worry together with irritable dysphoria and motor agitation with screaming. Sleep, appetite, energy levels and volition were disturbed. The patient exhibited irritable mood with paranoid thought content and delusions that neighbors were cooking weird things and up to no good. There was faulty reality testing and cognitive impairment and perceptual disturbance characterized by slow processing of information with impaired executive functioning. Judgment was markedly impaired; insight was poor/limited; and risk for violence and aggression was judged to be high with poor control of impulses. 
There were no acute general medical conditions. The patient had a history of hypertension and dyslipidemia with associated treatments. Physical examination and laboratory assessment and EKG were normal or negative or unremarkable. 

The patient is married, unemployed and high school educated. There are no legal issues or trauma issues in this case. The patient was involuntarily admitted to inpatient level care with plans for close observation and safety monitoring, structured milieu therapy, and resumption of pharmacotherapy with antipsychotic and mood stabilizing medication supplemented with as needed (prn) medications for anxiety and agitation with nicotine replacement therapy, and, monitoring for any withdrawal symptoms. The patient had the opportunity to participate in group, individual, and milieu therapy; she received counseling for the substance use disorders and declined smoking cessation. 

The patient had a stormy clinical course characterized by agitation, psychosis, and erratic behavior requiring staff intervention. The patient was prescribed Latuda, Depakote and Klonopin, titrated as clinically appropriate. She remained socially isolated with persistent symptoms of psychosis and irritability. The patient remained apprehensive, nervous, tense, irritable and agitated with deficient social skills and labile affect requiring prn medications and ongoing interventions from staff with monitoring. She did show improving mood and diminished levels of anxiety with improving insight. She was medication adherent but declined an injectable medication. By the date of discharge, the patient had participated in family meetings with her husband and case management had worked on a discharge plan. Again, the patient's anxiety diminished with improved mood and functioning and resolution of any safety concerns. She had participated passively in milieu activities and groups. She was discharged with clinically appropriate aftercare and medication that had been titrated to therapeutic dosages with tolerability. 

The health plan's determination is overturned. 

The patient did require the continued acute inpatient level care and the continued structure of an acute inpatient level setting in order to remain safe and to administer treatment for her psychiatric disturbance and co-occurring substance use disorder while conducting an evaluation, and while observing her functioning with the resumption/adjustment of clinically appropriate medications. 

The medical necessity for the continued inpatient level structure and monitoring is reasonable and in the patient's best interest in view of the patient's severe symptoms of mood disorder and psychosis; and need for safety monitoring in the context of persistent symptoms of psychosis and agitation, and the deteriorated functioning requiring staff interventions to address agitation and impulsive aggression. Additionally, the inpatient stay during this time interval is medically necessary in order to monitor the response to medications, to ensure that the patient will have a sustained response to treatment, and to continue to address the acute risk of aggressive or erratic behavior in the context of severe symptoms of bipolar mood disorder and co-occurring substance use disorder with active use of tobacco and cocaine. 

The patient's presentation and clinical features included severe symptoms of a mood disturbance with psychosis, risk for impulsive aggression, and deterioration in functioning with inability to care for self in the context of substance use disorder with multiple substances of abuse and medication non-adherence. The patient could not have been expected to participate in treatment at a lower level of care in this case scenario for the time interval under review. The medical necessity for intensive services and monitoring did warrant the continued acute inpatient psychiatric admission, as proposed.
The necessity for the continued inpatient level services is in keeping with prevailing standards of professional practice, and with the published practice guidelines and American Society of Addiction Medicine (ASAM) Criteria, referenced below, as well as NY State Office of Alcoholism and Substance Abuse Services (OASAS) Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) 3.0 Guidelines.