Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Bipolar Disorder

Treatment: Inpatient admission

The insurer is denied coverage for inpatient admissions. The denial is reversed. 

This was a female who presented to the Emergency Department (ED) with severe chest pain of 10 out of 10 in severity after a suicide attempt in which she took 12 iron pills and cut herself bilaterally on the wrists with a box cutter. The patient was admitted to the Medical unit. The patient reported feeling depressed, lonely, and emotionally overwhelmed and agitated. The patient reported poor sleep, appetite, and concentration. The patient's urine toxicology was positive for alcohol and cannabis. The patient had 4 vomiting episodes. The patient was treated with activated charcoal, intravenous (IV) fluids, Pepcid, Zofran, and Ativan. The patient was treated with Lithium, Trazodone, and Bupropion for Bipolar Disorder. The patient was stabilized and was transferred to the Psychiatric unit in the hospital for further inpatient treatment.

The American Psychiatry Association (APA) Practice Guidelines for the Treatment of Patients with Suicidal Behaviors reports that patients with suicide attempts are at high risk for suicide and also reports that patients with bipolar disorder and alcohol/substance use are at increased risk of suicide. In this case, this patient was considered a high risk patient and required inpatient acute hospital treatment in the hospital. Suicide attempts are the single most reliable indicator for suicide and this patient had a serious suicide attempt by 2 methods including overdose of iron pills and cutting both wrists with a box cutter. In the Emergency Department (ED), the patient had active depressive symptoms with positive urine toxicology for alcohol and cannabis. 

The APA Guidelines for the Treatment of Patients with Bipolar Disorders reports that the least restrictive level of care for safe and effective treatment is appropriate and also that patients with severe agitation, aggression, psychotic symptoms, suicidal or homicidal plan or intent or attempts, manic episodes, severe major depressive episodes, or inability to adequately care for basic self-care needs are in need of hospital treatment. In this case, this patient had a serious suicide attempt. The patient was noted to have agitation, emotional dysregulation, and depressed mood and required 24-hour inpatient treatment to better ensure her safety. The patient could not have been safely and effectively treated in a less restrictive setting. After stabilizing her acute overdose, the patient required inpatient psychiatric treatment which was supported by her transfer to the inpatient Psychiatric unit. The patient was considered an imminent danger to self at the time of admission and was in need of hospital treatment until the transfer to the Psychiatric unit. Thus, inpatient admission was medically necessary to safely treat this patient's medical condition.

The health plan did not act reasonably with sound medical judgment, and in the best interest of the patient.

Based on the above, the medical necessity for the inpatient admission is substantiated. The insurer's denial should be reversed.