Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Suicide attempt
Treatment: Continued Inpatient Psychiatric Admission
The insurer denied: Continued Inpatient Psychiatric Admission
The denial is overturned.

This case involves an adult male who took an intentional overdose of heroin, street Xanax, and street Klonopin and was brought into the emergency department with subsequent admission for intensive care and general medical services. The patient was stabilized medically and transferred for psychiatric inpatient treatment to address severe symptoms of depression (major depressive disorder) and anxiety associated with the suicide attempt by overdose. He had become increasingly anxious and depressed with suicidal ideation and deterioration in functioning prior to his admission with three emergency department visits including the last when he had taken the 
overdose with 10 milligrams (mg) of Klonopin and 25 milligrams of Xanax together with the opioid-heroin or methadone. The patient had a history of severe opioid use disorder and was receiving methadone maintenance treatment with 50 milligrams daily. The patient exhibited depressed mood with recent suicidal ideation and the attempted suicide. The patient was admitted to inpatient psychiatric care with plans for close observation, safety monitoring, and antidepressant pharmacotherapy, as well as continued treatment with methadone and withdrawal management. The patient made steady and slow progress addressing the guilt associated with work stress and negative cognitions. He received group, individual, and milieu therapies, as well as counseling regarding the opioid use disorder. He became increasingly cooperative with treatment. He initially had nausea, vomiting, and withdrawal symptoms consistent with benzodiazepine withdrawal, as well as an intense craving prompting a Klonopin taper and seizure precautions. He continued to require as needed medications going forward while the psychotropic regimen was titrated as clinically appropriate. The patient continued to display depression, and he remained fragile with suicidal risk requiring continued safety monitoring and safety observations. Sertraline was increased to 100 milligrams daily together with 100 milligrams of trazodone and continued use of as-needed Vistaril. Case management was working with the patient on a safe and clinically appropriated discharge plan culminating in a discharge to home with outpatient mental health services, a safety plan, and continued involvement in the methadone maintenance treatment program.

The requested health service treatment with continued inpatient psychiatric services for co-occurring disorders is medically necessary.

The patient required the continued acute inpatient level care and the continued structure of an acute inpatient level setting to remain safe and to administer treatment for the psychiatric disturbance while conducting an evaluation, and while observing his functioning with the resumption/adjustment of clinically appropriate medications. The clinical course was complicated by co-occurring opioid use disorder and the overdose with street benzodiazepines, as well as safety observation warranted in a patient at high risk for suicide. Additionally, the treatment team was planning for a safe and clinically appropriate disposition with the need to reconnect the patient to substance-related treatment including methadone maintenance. The medical necessity for continued 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 continued risk for suicidal behavior and co-occurring substance use disorder in view of these clinical features and the complicated presentation with history of a serious suicide attempt and need for withdrawal management, continued active treatment with safety monitoring was warranted in the context of the patient's deteriorated functioning. The necessity for continued inpatient level services reflects sound medical judgment in keeping with prevailing standards of professional practice, and with the published societal guidelines (Level of Care Utilization System [LOCUS] Guidelines) and American Society of Addiction Medicine (ASAM) Criteria. Additionally, New York State Office of Alcoholism and Substance Abuse Services (OASAS) Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) Criteria were met in this case scenario.