Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Overdose.
Treatment:  Inpatient admission.

The insurer denied coverage for inpatient admission.  The denial is overturned.

This is a patient who was admitted after a suicide attempt by overdose of 40-50 Naproxen pills and Xanax pills with intent to suicide, depressed mood, sleeping problems, and reportedly was forced into a sexual situation when manic the night prior. It was reported that this was a potentially lethal suicide attempt and that the patient had few protective factors against suicide, and the psychiatric consultant recommended involuntary psychiatric hospitalization when a psychiatric bed became available. The patient reportedly had diagnoses of bipolar disorder-depressed, post-traumatic stress disorder (PTSD), attention deficient hyperactivity disorder (ADHD), and was a transgender male. The patient reportedly took Wellbutrin and Depakote. The patient reportedly was put in 1:1 (one-on-one) observation for safety due to the serious suicide attempt and few protective factors and numerous risk factors for suicide. It was reported that the patient was awaiting a psychiatric hospital bed as no beds were available yet. The patient reportedly then improved enough for discharge with referral to a psychiatric partial hospital program (PHP).
  
The medical records provided enough specific evidence to support that they required inpatient hospital level of care due to serious potentially lethal suicide attempt. The Milliman Care Guidelines (MCG) 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 American Psychiatric Association (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 Naproxen and Xanax in a serious suicide attempt with intent and depressive symptoms including depressed mood. The patient also was considered a high risk due to bipolar disorder diagnosis as the American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Bipolar Disorder reports that patients with bipolar disorder are at increased risk for suicide. 

Notes on day 7 reported some improvement in mood and he denied suicidal ideation, so the recommendation was to observe the patient more and set up for psychiatric treatment upon discharge. 

It was reported that the patient was discharged when psychiatrically cleared for discharge by the psychiatrist. The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Suicidal Behaviors also 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. Even though the patient was not in an acute psychiatric hospital, they still required 24-hour inpatient hospital treatment due to their suicide attempt and they had 1:1 (one-on-one) observation and psychiatric consultation while in this medical setting. 

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for an inpatient admission is substantiated.