Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Suicide attempt

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is overturned
 

This patient was admitted to inpatient hospital treatment due to a suicide attempt with a resulting laceration requiring surgical intervention and she also had self-injurious behavior resulting in head trauma. She had suicidal intent, depressive symptoms including depressed mood, tearfulness, hopelessness, helplessness, worthlessness, guilt, and had poor eye contact. She was unkempt, and had incoherent speech, auditory and visual hallucinations, command and derogatory in nature, she was impulsive and lacked insight and judgment, and was unable to care for self. She had a diagnosis of Major Depressive Disorder-severe. She was admitted to the surgical unit for laceration repair and had 1:1 observation for suicide watch and safety and head trauma and had psychiatric consultants following her treatment. She took Mirtazepine and was started on Risperidone. She was discharged.
  
The medical records provided enough specific evidence to support that she required inpatient hospital treatment. The Milliman Care Guidelines (MCG) Behavioral Health Inpatient Level of Care Adult criteria reports that a patient needs to present as an imminent danger to self, imminent danger to others, with severe psychiatric or behavioral symptoms, have a severely dysfunctional living including inability to care for self, unwillingness to participate voluntarily, or a less restrictive level of care is not feasible meet criteria for inpatient behavioral health level of care. 

In this case it was reported that this patient had 2 suicide attempts resulting in a laceration that required surgical intervention and then had self-injurious behavior which resulted in head trauma. She had severe depressive symptoms including depressed mood, tearfulness, hopelessness, helplessness, worthlessness, guilt, had poor eye contact, was unkempt, and had incoherent speech, auditory and visual hallucinations command and derogatory in nature, and she was impulsive and lacked insight and judgment, and was unable to care for self.  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 a high-risk patient who made 2  intentional suicide attempts including slashing herself with a kitchen knife and also banging her head into a sharp corner resulting in head trauma. She was considered an imminent danger to self and still had severe reported psychiatric symptoms including severe depressive symptoms including hopelessness and also had psychotic symptoms and was unable to care for herself. She could not safety be treated in a less restrictive setting other than an inpatient hospital setting.

Based on the above, the insurer's denial must be overturned. 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 the hospital admission is substantiated.