Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Psychotic symptoms

Treatment: inpatient mental health treatment

The insurer denied coverage for inpatient mental health treatment. The denial is upheld. 

This patient is a male who was admitted for inpatient mental health treatment due to psychotic symptoms, including disorganized and delusional thinking, agitation, and irritable mood.  The patient used cannabis daily. The patient's psychiatric history was also significant for psychotic disorder and past psychiatric hospitalizations.  The patient was treated with Tegretol and Haldol, and was stabilized and discharged.

The MCG Behavioral Health GRG (BG-BHG) indicates that hospital admission is needed for appropriate care of the patient if the patient presents with behavioral health disorder and is an imminent danger to self and others, or the patient has severe psychiatric or behavioral symptoms and/or has a behavioral health disorder and is severely dysfunctional in daily living for adult (i.e. inability to care for self). The guidelines also indicate hospital admission is indicated if the situation and expectations are appropriate for inpatient care because the patient is unwilling to participate voluntarily, or a less restrictive level of care is not feasible to meet the patient's needs.

The InterQual 2018 Behavioral Health-Adult and Geriatric Psychiatry-Inpatient medical necessity criteria reports that if one has assaultive behavior within 24 hours, catatonia, command hallucinations to harm self or others, destruction of property with poor impulse control within 24 hours, disorganized behavior, unstable eating disorder, fire setting, homicidal or suicidal attempt within 24 hours, suicidal or  homicidal ideation with high risk for an attempt, mania, risk of harm to self or others, non-suicidal self-injury and continued danger to self, positive psychotic symptoms with risk of harm to self or others, posttraumatic stress disorder (PTSD) with risk of harm to self or others, psychomotor agitation and potential for violence, severe social withdrawal and refusing treatment, unavailable support or inability to provide needed care and supervision and there is acute deterioration in functioning then meet criteria for inpatient treatment.

This patient had severe psychiatric symptoms requiring hospital treatment including psychotic symptoms as it was reported that the patient had disorganized and delusional thinking, agitation, irritable mood, and the patient reportedly was disrobing.  The patient had multiple past psychiatric hospitalizations. However, other notes indicate that patient has improved mood, congruent affect. The patient dressed in clean, casual street attire, attending to ADLs independently. Speech is normal; Fair eye contact maintained; Patient denies SI/HI/AVH; Patient adherent with medication regimen, no side effects noted; Patient reports sleep and appetite are adequate; Patient interacting with select staff and peers; Attending select groups and activities; Patient focused on discharge, no apparent distress.

As a result, the recommendation is to uphold the previous decision and deny coverage for inpatient mental health treatment in this hospital.  It did appear that the health care plan acted reasonably, with sound clinical judgment, and in the best interests of the patient.  

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