Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Depressive symptoms; Bipolar Disorder; Post-Traumatic Stress Disorder (PTSD)

Treatment:  Inpatient behavioral health admission

The insurer denied coverage for inpatient behavioral health admission.  The denial reversed.

This patient is a male who was admitted to this inpatient mental health treatment in this hospital due to worsened depressive symptoms including suicidal ideation with a plan to hang himself.  The patient had reports of worsened depressed mood, low energy with inability to get out of bed, feelings of hopelessness and helplessness, and irritable mood.  It was reported that he had a history of a past suicide attempt.  He had a positive toxicology for opiates and amphetamines.  He had diagnoses of Bipolar Disorder and Post-Traumatic Stress Disorder (PTSD).  He had a recent psychiatric hospitalization and was discharged after a 27-day stay.  He reported fleeting hallucinations, and he had impaired social skills.  He remained depressed in mood with feelings of hopelessness and helplessness and had medication changes.  He had Fluoxetine tapered and then discontinued, and he was started on Trintellix.  This medication was increased.  He also took Nortriptyline, Trazodone, Alprazolam, and Lithium.  He was discharged.

The insurer denied coverage for continued inpatient mental health treatment in this hospital as not medically necessary treatment.  This reviewer disagrees with the decision to deny coverage for continued inpatient mental health treatment in this hospital.  The charts notes provided enough specific evidence to support that he required 24-hour hospitalization until discharge, as he was considered a high risk patient.  The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Suicidal Behaviors report that patients with past suicide attempts are at high risk of suicide and that past suicide attempts are the strongest risk factor for suicide.  It also reports that patients with comorbid substance use and bipolar disorder and patients with hopelessness are at increased risk for suicide.  The patient had all of these reported.

He continued to report dysphoric and depressed mood and feelings of hopelessness and helplessness, and Trintellix was increased.  He continued to report dysphoric and depressed mood and feelings of hopelessness and helplessness afterwards.  He had some reported improvement on a specified date as he reported feeling less hopeless and helpless, though he still had depression.  Notes on subsequent days reported a depressed mood and feelings of hopelessness and helplessness; therefore, he still was at risk for suicide.  Notes on the date before discharge did not report further hopelessness or significant depression, but he required this day of observation without depressive symptoms and hopelessness, as he was a high risk patient due to a past suicide attempt, suicidal plan on admission, comorbid substances of use, hopelessness, and a recent long hospital stay with a rapid decompensation after discharge.  

As a result, reverse the previous decision and approve coverage for continued inpatient mental health treatment at this hospital.  The health care plan did not act reasonably or with sound medical judgment or in the best interests of the patient.

The carrier's denial of coverage for the continued inpatient behavioral health admission is reversed.  The medical necessity is substantiated.