Appeal type: Medical necessity
Decision: Overturned

The patient is a female who was medically screened in the emergency department and admitted for acute inpatient psychiatric treatment. The patient had become increasingly anxious and depressed with suicidal ideation and self-harming behavior culminating in her presentation. A breakup initiated by her boyfriend had precipitated the recurrent depressive episode in the context of bipolar I mood disorder. She had used a box cutter to cut her arm and legs that prompted emergency medical services and her presentation to the emergency department where she had been brought in by the boyfriend. The patient has a history of bipolar disorder and severe depressive episodes and psychiatric treatment with therapy and medications. She had been recently discharged from another inpatient treatment facility but failed to adhere to her medication regimen and was using alcohol and cannabis with several shots of liquor and daily use of marijuana. Thus, her presentation was characterized by worsening symptoms of depression and suicidal ideation in the context of multiple psychosocial stressors and severe substance use disorder with alcohol and cannabis class substances of abuse.

The patient was admitted to inpatient level-of-care with plans for close observation, safety monitoring, structured milieu therapy, and pharmacotherapy with resumption of lithium and the addition of lamotrigine supplemented with as needed (prn) anxiolytic and antipsychotic medications and melatonin for insomnia.  The patient continued to exhibit severe symptoms of depression with dysphoria and anxious affect. Her medications were tolerated, as well as the use of haloperidol and Ativan to address bouts of agitation and aggressive impulses or urges to self-harm. Medications were titrated as clinically appropriate with slow improvement in the patient's mental status and functioning. Dialectical behavioral therapy (DBT) and substance-related treatments including vitamin replacement therapy were provided to address borderline personality traits/disorder and the co-occurring substance-related conditions with alcohol and cannabis use disorders. The patient gradually improved and became better engaged in therapeutic interventions and was more cooperative with staff and social with peers.

A family meeting was held to address discharge planning and consider an appropriate disposition. The patient's mood was notably improved with diminished anxiety and improved functioning though she remained anxious with depression. She denied suicidal ideation, plan or intent. Insight, judgment and impulse control remained impaired, and, the staff was addressing the continued treatment for the co-occurring alcohol and cannabis use disorders with motivational techniques. The patient was discharged from inpatient level care with step down to outpatient level care and return to her grandmother's home.

The health plan's determination of medical necessity is overturned.

The patient required the admission and the continued acute inpatient level care; and, the continued structure of an acute inpatient level setting through discharge was warranted in order to provide safety monitoring and to administer treatment for the psychiatric disturbance while conducting an evaluation, and while observing her functioning with the resumption/adjustment of clinically appropriate medications including the use of evidence-based psychotherapeutic interventions and motivational techniques targeting the co-occurring substance use disorders.
The medical necessity for the continued acute 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 co-occurring substance use disorders; in view of the severe psychosocial stressors that precipitated the presentation and recurrence of self-harming behaviors; and, in view of the need for continued active treatment in the context of deteriorated functioning and the imminent risk for harm to self.
Additionally, the inpatient stay during the time interval under review is medically necessary in order to monitor the response to medications, to insure that the patient will have a sustained response to treatment, and to continue to address the acute risk of suicidal or self-harming behavior in the context of severe symptoms of bipolar mood disorder with depression and the co-occurring substance use disorders that were only in partial remission. The necessity for the continued inpatient level services reflects sound medical judgment in keeping with prevailing standards of professional practice, and with the published practice guidelines and criteria, referenced below, as the application of NY State Office of Alcoholism and Substance Abuse Services (OASAS) Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) 3.0 and American Society of Addiction Medicine (ASAM) Criteria, referenced below.