Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis:  Major Depressive Disorder (MDD).
Treatment:  Inpatient Mental Health.

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

This patient is a male, who was admitted for inpatient mental health treatment due to his active, depressive symptoms including suicidal ideation and plan, depressed mood, hopelessness, helplessness, poor activities of daily living (ADL's), as well as alcohol and benzodiazepine use.  The patient had a reported diagnosis of Major Depressive Disorder (MDD).  The patient reported a history of self-injurious behavior including cutting self and multiple past psychiatric hospitalizations.  The patient was admitted and was treated with Sertraline, Abilify, and Naltrexone.  The patient was discharged.

The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Major Depressive Disorder reports that the least restrictive level of care for safe and effective treatment is appropriate.  It also states that patients with suicidal intent or plan or behaviors, or who present as an imminent danger to self or others are in need of hospital treatment.  It also states that patients with inability to adequately care for their basic needs or severe psychomotor slowing may need hospitalization.  This was the case for this patient initially, as he reported multiple suicidal plans and intent with severe depression.  The patient still had reports of significant depression from specified dates according to the chart notes provided.  Notes from a specified date reported that the patient had depressed mood, blunted affect, isolative and guarded behavior, poor self-care, internal preoccupation, intrusive thoughts, thought blocking, and psychomotor retardation.  The patient was still at risk to harm self.  Notes reported that the patient was still depressed in mood with flat affect, guilt, was unkempt, and spoke about feeling hopeless as a trigger to drinking.  The patient was still at risk for harm to self and supported the need for continued 24-hour hospital treatment then.  

However, as of a specified date, the patient's chart notes did not report severe depressive symptoms.  Notes reported that the patient was feeling good, had no craving for alcohol anymore, and that he denied anhedonia, depression, suicidal or homicidal ideation, plan, or intent, or hallucinations, and his insight and judgment were improving with fair impulse control.  Notes reported that the patient denied depression, suicidal or homicidal ideation, plan, or intent, or hallucinations, and that he felt ready for discharge because he was not suicidal anymore.  Notes reported that the patient denied depression, suicidal or homicidal ideation, plan, or intent, or hallucinations.  The patient reportedly was discharged. 

Based on the review of the medical record, the chart notes did not report that this patient had severe depressive symptoms, suicidal ideation, plan, or intent, severe psychomotor retardation, and did not have reports of specific identifiable or quantifiable treatment goals or objectives that could only be achieved in a 24-hour hospital setting then or that could not be achieved in a less restrictive setting then. 

The health plan acted reasonably with sound medical judgment and in the best interest of the patient to deny coverage for inpatient hospital stay for specified dates.  However, the health plan did not act reasonably with sound medical judgment and in the best interest of the patient to deny coverage for inpatient hospital stay for other dates specified.

The carrier's denial of coverage for the inpatient hospital admission should be partially overturned.