Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Ingestion of Naproxen.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld.

The patient is a female who was noted to have been brought to the emergency department following a suicide attempt. Acute inpatient medical hospitalization was noted to have been previously denied as not medically necessary. 

The patient was diagnosed with major depressive disorder, single episode, severe with psychotic features. The patient was reported to have been admitted following an intentional overdose on 20 to 40 of 500 milligrams (mg) naproxen and worsening symptoms of depression in the context of significant psychosocial stressors. The patient was noted to have initially presented with nausea and vomiting. She was noted to have significant ongoing symptoms of depression including anhedonia, hopelessness, helplessness, poor sleep, decreased appetite and difficulties with concentration. The patient was also reported to have command auditory hallucinations and paranoia. 

The patient was noted to have been initially admitted to the acute inpatient psychiatric unit. The patient was provided with individual, group and family therapy while admitted to the psychiatric inpatient unit. The patient was not started on any psychotropic medications during her acute inpatient psychiatric stay. The patient was noted to have worsening anemia including decrease in hemoglobin. Her presentation was noted to have been concerning for gastrointestinal bleed. 

The patient was noted to have been subsequently transferred to an acute medical unit. She was not noted to have had any significant physiological instability that required continued monitoring or interventions in an inpatient setting. The patient was noted to have had an endoscopy procedure performed which was noted to have been largely unremarkable. Biopsy indicated Helicobacter gastritis and possible reflux esophagitis. Extensive hematological workup was also noted to have been performed. Biochemical laboratory testing was noted to have been largely unremarkable and consistent with the patient's medical history of anemia. The patient was noted to have some hypophosphatemia and hyperchloremia. Hyperbilirubinemia, hypertension, and abdominal pain were noted to have resolved.

The patient was noted to have persistent microcytic anemia with iron deficiency. She was noted to have been given blood transfusion due to severe anemia. The patient was noted to have been recommended to start fluoxetine. The patient was no longer reported to have any suicidal thoughts, plans or intent. There was no indication that the patient continued to have any symptoms suggestive of psychosis including hallucinations, delusions, or paranoia. She was not reported to have any significant changes in appetite or sleep. She was noted to have been eating appropriately and was noted to be able to maintain adequate nutrition. There was no indication of the patient had any significant functional impairments including age-appropriate activities of daily living or self-care.

No, the proposed treatment (acute inpatient stay) was not found to be medically necessary.

The patient was not noted to have had any significant physiological instability that required monitoring or interventions in an inpatient setting at the time of her admission. She may have been treated safely and effectively in a less restrictive setting in lower level of care for her ongoing medical conditions. Biochemical laboratory testing was noted to have been largely unremarkable and consistent with the patient's previous medical history of anemia. There was no indication of the patient had any significant hemodynamic instability, arrhythmias, significant electrolyte imbalances, respiratory insufficiency, mental status changes or neurological abnormalities.

The patient was noted to have had an endoscopy procedure performed which was noted to have been largely unremarkable. Biopsy indicated Helicobacter gastritis and possible reflux esophagitis. Extensive hematological workup was also noted to have been performed. The patient was noted to have some hypophosphatemia and hyperchloremia. Hyperbilirubinemia, hypertension, and abdominal pain were noted to have resolved. The patient was noted to have persistent microcytic anemia with iron deficiency. She was noted to have been given blood transfusion due to severe anemia. The interventions to correct anemia may have been provided outside of an acute medical setting.

The patient was no longer reported to have any suicidal thoughts, plans or intent. There was no indication of the patient continued to be at imminent risk of harm to herself or others. She was noted to have been recommended to start fluoxetine. There was no indication that the patient continued to have any symptoms suggestive of psychosis including hallucinations, delusions, or paranoia. She was not reported to have any significant changes in appetite or sleep. She was noted to have been eating appropriately and was noted to be able to maintain adequate nutrition. There was no indication of the patient had any significant functional impairments including age-appropriate activities of daily living or self-care.

Yes, the health plan was noted to have acted reasonably, with sound medical judgment and in the best interest of the patient.

The patient was not noted to have had any significant physiological instability that required monitoring or interventions in an inpatient setting at the time of her admission to the acute medical unit. She may have been treated safely and effectively in a less restrictive setting in lower level of care for her ongoing medical conditions. Biochemical laboratory testing was noted to have been largely unremarkable and consistent with the patient's previous medical history of anemia. There was no indication of the patient had any significant hemodynamic instability, arrhythmias, significant electrolyte imbalances, respiratory insufficiency, mental status changes or neurological abnormalities. There was no indication of the patient required 24-hour medical and nursing care. Therefore, the health plan was noted to have acted reasonably, with sound medical judgment and in the best interest of the patient.