Appeal type: Medical necessity
Decision: Overturned

Dx: Mental Health
Tx: Mental Health: Inpatient
Denied: Inpatient stay
Denial: OVERTURNED in whole

The case involves a male who presented to the emergency department for evaluation of an acute exacerbation of schizophrenia. The patient had prominent delusions with internal preoccupation and paranoid themes. He reported worsening symptoms of depression with suicidal ideation. He had stopped his psychotropic medications and was non-compliant with his outpatient mental health treatment. He was noted to be in a debilitated state with mental confusion and decline in functioning representing a safety issue. Thus, the patient was subsequently admitted after medical clearance that included physical examination, laboratory assessment, chest x-ray, and electrocardiogram (EKG), and admitted for acute inpatient psychiatric services for treatment of the exacerbation of his chronic psychotic disorder best characterized as unspecified schizophrenia.

The patient has a history of psychiatric treatment for schizophrenia with multiple inpatient hospitalizations, and a history of medication non-adherence.

There were no acute general medical problems in this case. He was obese with gynecomastia.

The patient is homeless and lives in a shelter. He is unemployed. There was no evidence for substance use and no legal issues in this case.
Mental Status Examination on admission: The patient was guarded with poor eye contact and cognitively impaired with thought disorder and perceptual disturbance characterized by auditory hallucinations and preoccupation with internal stimuli. He displayed irritable and dysphoric mood with anxiety, nervousness, apprehension, tension, and excess worry together with ideas of reference to being followed by the Federal Bureau of Investigation (FBI) and others. He demonstrated disorganized thought processing with thought blocking and with content that was illogical and incoherent. He had decreased concentration, energy, sleep, and volition, and presented with impaired judgment, poor insight and poor control of impulses with inability to care for self.

The patient's treatment plan included safety monitoring and resumption of antipsychotic medication targeting symptoms of psychosis, as well as supportive measures to encourage oral intake and to facilitate reality testing. He had the opportunity to participate in group therapy and psychoeducation provided within the milieu, as well as activity therapies to support healthy living and social skills. Risperidone and Cogentin were prescribed and titrated as clinically appropriate to 4 milligrams (mg) twice daily (bid) with plans to proceed to the use of a long-acting injectable formulation. 

On the day of discharge, the patient was noted to be more stable with linear thought processing that was more logical, and goal directed. He was euthymic with fair insight and judgment. He denied hallucinations and demonstrated clear speech with better eye contact and communication skills. There were no remaining safety issues, and an aftercare appointment had been arranged with case management. He was discharged to a shelter with medication, as indicated.

The subject under review is the medical necessity for the inpatient stay.

The health plan's determination is overturned, in whole.

The requested health service/treatment of inpatient stay was medically necessary. The patient's continued hospital stay for treatment of an exacerbation of a psychotic disorder (schizophrenia) did require the inpatient level services, structure, and monitoring through discharge. The patient's severity of symptoms, and inability to effectively participate in treatment at a lower level of care, persistent functional impairment, and safety issues related to persistent symptoms of acute psychosis were clinical factors and treatment dimensions that necessitated the continued acute inpatient hospital care, structure, and monitoring, as proposed through discharge.
The medication adjustments and safety monitoring together with attention to the need for a safe and clinically appropriate discharge and disposition, the support of functioning and the continued application of multimodal treatments, as well as assurance of medication adherence, were factors that did warrant the continued inpatient level treatment through discharge; the patient could not have been effectively managed at a lower level of care during the time interval under review.