Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Depression.
Treatment:  Inpatient Mental Health Stay.

The insurer denied the Inpatient Mental Health Stay.  The determination is overturned.

The patient was admitted for acute inpatient psychiatric treatment.  She was brought to the emergency department with suicidal ideation and worsening symptoms of depression in the context of cannabis use.  She had become increasingly anxious and depressed with suicidal ideation and paranoid thinking.

The patient has a history of posttraumatic stress disorder (PTSD) related to sexual assault, and co-morbid attention deficit hyperactivity disorder (ADHD) and co-occurring substance use disorder with use of cannabis.  The recent use of cannabis was thought to have precipitated the patient's onset of paranoia and anxiety.  There was a history of "psychogenic seizures" and trauma-related symptoms following a sexual assault.  Psychotropic medication regimen included Vyvanse, Prozac and low-dose Seroquel, as well as prazosin to address nightmares.

The mental status examination revealed a guarded and uncooperative female with depressed mood and anxious affect.  The patient was tobacco dependent with mild use.  There were no acute general medical conditions.  Urine drug screen was consistent with history and positive for cannabis/tetrahydrocannabinol (THC).

The patient was admitted for close observation, safety monitoring, structured milieu therapy, and pharmacotherapy with adjustments.  The patient remained depressed, anxious and motor agitated with pacing and bouts of psychotic terror requiring as needed (prn) use of Haldol and Ativan.  Prozac was stopped and Seroquel was increased with titrations from 25 milligrams (mg) to 200 mg daily; she was medication adherent with tolerability. 

The patient became increasingly cooperative with treatment and more social with peers with improved mood and reality testing.  She reported feeling better and had no additional bouts of agitation or screaming episodes.  A family conference was held with case management in order to address discharge planning.  By the day of discharge, the patient's symptoms were mostly improved.

At issue is the medical necessity of continued inpatient mental health stay.

The patient required the continued acute inpatient level care and the structure and monitoring of an acute inpatient level setting in order to remain safe and to administer treatment for her psychiatric disturbance and co-occurring substance use disorder.  She warranted the continued inpatient level care while conducting an evaluation of response to medication adjustments (discontinuation of Prozac and titration of Seroquel), and while observing her functioning and maintaining abstinence from cannabis.  The clinical course was complicated by a recent increase in cannabis use disorders and psychosocial stress related to trauma-related symptoms.

The inpatient stay was medically necessary in order to monitor the response to medication adjustments, to insure that the patient would have a sustained response to treatment, and to continue to address the acute risk of suicidal behavior in the context of severe symptoms in a patient who presented with impaired judgment and poor control of impulses.  The necessity for continued inpatient level services reflects sound medical judgment in keeping with prevailing standards of professional practice, and with the published practice guidelines and criteria, including the appropriate application of NY State Office of Alcoholism and Substance Abuse Services (OASAS) Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) 3.0 criteria pertaining to the cannabis use disorder.