Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Mental Health
Treatment: Inpatient Hospital
The health plan denied the inpatient hospital stay as not medically necessary. 
The health plan's determination is partially overturned. Approved first 4 days. The patient could have been discharged two days earlier than her actual discharge.

This is a review for an inpatient stay for a diagnosis of intentional diphenhydramine overdose in a suicide attempt.

The patient involved in this case was a female with no known prior history of psychiatric illness who on the day of emergency department (ED) presentation ingested 30 pills of 25 mg diphenhydramine in a suicide attempt. She reported chest pain and blurry vision at home before notifying her parent of the ingestion. Emergency Medical Services (EMS) was called and described the patient as "lethargic". En route to the ED, the patient had 20 seconds of generalized tonic-clonic seizure activity with limb jerking and upward rolling of her eyes.

During her hospital course, the patient was seen daily by psychiatry. The patient reported feeling "sad and anxious" with "thought content including suicidal ideation". She began self-cutting years ago and had tried to commit suicide once before by taking medications (ibuprofen). On the day she presented to the ED, she reported getting upset with both her boyfriend and best friend and "didn't think there was a point on living and wanted to not wake up". She stated that she was aware that the overdose would kill her and wanted to do that. Stressors for the patient included school stress, financial strain, relationship difficulties. She endorsed poor appetite and loss of interest in prior activities. It was also disclosed that she was vaping and using marijuana daily for anxiety. The patient's family was described as "very supportive", but mother reported that she was unaware that patient was feeling depressed or suicidal. Assessment by psychiatry was as follows: patient is "at high risk for suicide, danger to self, based on the seriousness of her attempt, prior suicide attempts, lack of full insight into seriousness of situation, she is not currently in therapy. Will recommend inpatient psychiatric hospitalization for observation and stabilization treatment."

I overturn, in part, the health plan's determination of medical necessity for inpatient admission. Approved first 4 days. The patient could have been discharged two days earlier than her actual discharge.

Yes, the requested treatment of the inpatient stay was medically necessary for this patient.

The patient presented with an intentional overdose of diphenhydramine in a suicide attempt. Further evaluation by psychiatry team determined that given the seriousness of her attempt, the fact that the patient had a prior suicide attempt, the absence of current in place therapy and the lack of insight into the seriousness of her mental health made the patient high risk for suicide and a danger to herself. Inpatient psychiatric hospitalization was recommended, and the patient was stated to require 1:1 observation until transfer. Daily notes repeatedly state that the patient was not psychiatrically cleared for discharge home.

These recommendations for admission to an inpatient psychiatric facility and 1:1 observation until transfer are in agreement with recommendations from The Joint Commission, the American College of Emergency Physicians and several large children's hospitals (3-8). To discharge this patient home instead of transfer to an inpatient psychiatric facility with the recommendation that "follow up care could have been at the child's doctor's office or at a clinic" would have put the patient at risk.