Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Depression
Treatment: Inpatient mental health admission 
The insurer denied the Inpatient mental health admission.
The denial is upheld. 

The patient is a adult male with a history of major depressive disorder with associated symptoms of anxiety. He had been treated as an outpatient with antidepressant medications that had not been effective. He was brought by his family to the emergency department for an evaluation of worsening symptoms of depression over a two-month time frame. His severe depression was precipitated by job loss. He reported that he had not left the house in two months, and that was sleeping excessively and had no desire to do anything. The patient was medically screened and admitted to acute inpatient psychiatric care.

The patient's mental status examination revealed symptoms of depression with general symptoms of anxiety and somatic concerns including loss of appetite with a twenty-pound weight loss, low energy, and hypersomnia. He exhibited helplessness, hopelessness, low self-worth, anhedonia, depressed mood, anxious affect, and poor concentration. There were no severe symptoms such as thought disorder, mania, psychosis, or severe cognitive impairment. He was preoccupied with multiple stressors within the primary support, social, economic and occupational domains. Again, he reported low energy and decreased appetite with sleep disturbance, and he had limited insight and impaired judgment. There were no safety concerns with regard to suicidal risk, and the patient denied suicidal ideation.

There were no acute general medical issues or substance use disorders in this case. The patient had chronic conditions, including insulin-dependent type II diabetes mellitus, hypothyroidism, and GERD (gastroesophageal reflux disease) with associated treatments. Laboratory assessment revealed elevated blood glucose, but it was otherwise unremarkable or normal. EKG (electrocardiogram) was normal. Drug screen was negative and consistent with history that included no substance use disorders.

The patient is single, unemployed with recent job loss, and lives alone with family support. There were no legal issues or trauma history in this case.

The patient received a comprehensive evaluation with treatment plan that included safety monitoring, individual and group therapy, education, and medications to address the patient's mood disturbance as well as prn (as needed) medications to address anxiety and sleep disturbance (clonazepam and trazodone). From the time of admission through discharge, the patient engaged in treatment including participation in groups and educational sessions and milieu activities. There were no complications of treatment, and the patient consistently denied suicidal ideation. The case manager worked to achieve a transfer to another facility that was preferred by the patient's family, and the patient was discharged the following day after admission. 

No, the Inpatient mental health admission was not medically necessary for this patient.

The patient's admission and initial treatment for mood disturbance and severe psychosocial stressors did not require inpatient level services, structure, and monitoring. The patient's evaluation in the emergency department did not identify safety risks that would have necessitated acute inpatient level care. The effective treatment of this patient's mood disorder did not require acute inpatient level services in order to be safely and effectively provided for his mental health condition, major depressive disorder. He was generally motivated to participate in treatment and capable of participating in treatment targeting mood disturbance and functioning. The patient did not display severe psychiatric symptoms such as psychosis, mania, perceptual disturbance, severe cognitive impairment or suicidal ideation. plan or intent. He had family support for his treatment and was therefore amenable to treatment at a lower level of care. Additionally, the symptoms of the depressive disorder and efforts to address his psychosocial stressors were amenable to treatment at a lower level of care, as the health plan asserts.

This answer is consistent with the scientific literature and practice guidelines, referenced below, as well as prevailing standards of care and New York State instruction for medical necessity reviews.

The health plan's decision to deny coverage for the requested treatment, Inpatient Mental Health Services is reasonable in this case scenario. The patient was cooperative and motivated to engage in treatment with family support. The patient had no severe symptoms noted and he did not have complicating general medical or clinical features with safety concerns that would have warranted 24-hour monitoring or acute inpatient structure. The patient did not exhibit risk for suicidal behaviors, and had consistently denied suicidal ideation, plan or intent of self-harm. He was generally compliant with the treatment plan and adherent with medication, and he was attending to daily activities. He was therefore able to effectively engage in lower level care in order to address the depressive disorder and pertinent psychosocial stressors noted in this case.