Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Intentional overdose with suicidal intent

Treatment: full hospital admission

The insurer denied coverage for full hospital admission

The denial is overturned

The patient was admitted to the PICU (pediatric intensive care unit) after an intentional overdose of her mother's Lexapro, in which she took 5 x 10 mg (milligrams) Lexapro pills. She was reportedly depressed and stated that she was really sad, having crying spells, anxious mood and nervousness. She reportedly had a history of cutting and burning herself. She reportedly was living with her parent and siblings and attending 11th grade and is overwhelmed due to schoolwork. During admission, she was monitored for serotonin syndrome and cardiac arrythmias due to excess serotonin in Lexapro. Cyproheptadine was ordered if needed for possible serotonin syndrome. She reportedly denied suicidal ideation, intent, or plan and was medically cleared for discharge.
   
The medical records provided enough specific evidence to support that the patient considered an imminent danger to herself, due to intentional overdose with suicidal intent and more depressed mood. According to the Milliman Care Guidelines (MCG) Inpatient Behavioral Health Level of Care Child-Adolescent medical necessity criteria guidelines, it reports that one needs to present as an imminent danger to self  or others with an imminent risk of suicide attempt or serious harm to self or homicidal behavior or harm to others, current suicidal or homicidal plan or plans of harm to self or others, command auditory hallucinations suicidal or self-harm in nature or homicidal or with harm to others, or persistent thoughts of suicide or self-harm or violent impulsive acts likely to result in homicide or serious harm to others that cannot adequately be monitored at a lower level of care,  severe psychiatric or behavioral symptoms with either bothersome hallucinations or delusions, disorganized speech, bizarre or catatonic behavior, severe negative symptoms, severe mania, depression, anxiety, or comorbid substance use with inability to control use, severe impairment in cognition, memory, judgment, or impulse control, aggressive behavior or severe agitation, or a severely dysfunctional living environment, or inability or unwillingness to be treated at a less restrictive level of care. 

In this case, chart notes reported that she actually had an intentional suicide attempt with suicidal intent and worsened depression, including feeling really sad and overwhelmed, so she was considered an imminent danger to self and in need of hospital treatment.  She also had a history of self-harm behaviors including cutting and burning self. She reportedly took five of her mother's 10 mg Lexapro pills and her mother found her.

The APA (American Psychiatric Association) Practice Guidelines for the Treatment of Patients with Suicidal Behaviors reports that patients with suicide attempts are at high risk of suicide. Suicide attempts are the single most reliable predictor of suicide. The APA Practice Guidelines for the Treatment of Patients with Suicidal Behaviors reports that patients may require more time in the hospital to better assess suicide because they sometimes do not tell the truth regarding their suicidal thoughts in order to leave the hospital, and that observation in the hospital is appropriate to better ensure their safety. This patient was considered a high-risk patient due to a suicide attempt and was considered an imminent danger to self and in need of inpatient hospital treatment. Even though she was not in an acute psychiatric hospital and was in the PICU, she still required 24-hour inpatient hospital treatment due to her suicide attempt until she was deemed safe for discharge. She reportedly was shaking, had nausea and vomiting and required hospital monitoring for possible serotonin syndrome or cardiac arrhythmia. She reportedly denied suicidal ideation, plan, or intent and was medically cleared for discharge. 

The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for the full hospital admission is overturned. Medical Necessity is substantiated.