Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Suicidal ideation with plan to overdose; depressed mood 

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission. The denial is upheld. 

This patient is a female who was admitted to this inpatient mental health treatment in this hospital due to suicidal ideation with plan to overdose, depressed mood, low energy and motivation, isolative behavior, as well as a decline in functioning.  She had a history of alcohol use including drinking one bottle of tequila prior to admission.  She had a driving under the influence (DUI) but the charges were dropped.  She had diagnoses of Major Depressive Disorder, Alcohol Use Disorder, and Generalized Anxiety Disorder.  She took Lexapro, Vistaril, and Melatonin.  She was discharged. The insurer denied coverage for continued inpatient mental health treatment.

This reviewer agrees with the decision to deny coverage for continued inpatient mental health treatment in this hospital as the chart notes did not provide enough specific evidence to support that she still was considered an imminent danger to self or others and was still in need of only 24-hour acute psychiatric hospitalization. The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Major Depressive Disorders report that the least restrictive level of care for safe and effective treatment is appropriate and that patients with suicidal plan or intent or behaviors, or inability to adequately care for basic needs are candidates for hospitalization.  

As of a specified date, there were no reports of suicidal thoughts, plan, or intent, psychotic symptoms, severe depression interfering with her ability to care for basic needs, or acute medical instability.  Notes on that date reported that she denied hallucinations, homicidal ideation, and there were no reports of current suicidal ideation, plan, or intent. She had reports of a linear thought process, improving judgment, and there were no reports of over delusional thinking. There were no reports on the day before of suicidal or homicidal ideation, plan, or intent, psychotic symptoms, severe behavioral symptoms, or inability to adequately care for her basic needs.

As of a specified date, there were no reports of suicidal or homicidal ideation, intent, or plan, inability to adequately care for basic needs, manic episodes, psychotic symptoms, or self-injurious, aggressive, threatening, or agitated behavior.  Also, as of that said date, the chart notes did not provide enough specific evidence that she was an imminent danger to self or others or unable to adequately care for her basic needs.  As of then, there were no reports of specific identifiable or quantifiable treatment goals or objectives that could only be achieved in a 24-hour acute psychiatric hospital setting or that could not be achieved in a less restrictive setting.  

As a result, uphold the previous decision and deny coverage for inpatient mental health treatment at this hospital.  The health care plan acted reasonably and with sound medical judgment and in the best interest of the patient.

The carrier's denial of coverage for the inpatient admission is upheld.  The medical necessity is not substantiated.