Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Thoughts of Self Harm.
Treatment: Continued Inpatient Mental Health Treatment.
The insurer denied the Continued Inpatient Mental Health Treatment.
The denial is upheld. 

The patient is a male who received inpatient mental health treatment. The patient was initially admitted due to thoughts of self-harm. On initial admission, the patient expressed a plan to overdose on medications. He stated "I don't want to kill myself but I did consider shooting myself or cutting myself." He was described by his family as being delusional and paranoid and being without sleep for many days.

Clinical history indicates a prior diagnosis of schizoaffective disorder, previously being Covid 19 positive, hypertension, hyperlipidemia, renal stones. He also had a history of hernia repair. He had a history of cataract surgery. He had continuing problems with his vision after this surgery. The patient had been started on Lexapro by a neurologist prior to admission though stopped it after two weeks because he felt it was not helping. He later took Klonopin, but it made him tired. He went to another psychiatrist and was started on an antipsychotic medication but stopped taking it several weeks later.

On initial mental status examination, the patient was described as suspicious, dysphoric, tearful, anxious, illogical with perseveration, impaired reality testing, hopeless, helpless, visual hallucinations, Persecutory delusions, suicidal ideation and impaired concentration, attention, insight, and judgment. He was initially started on Klonopin and Haldol PRN (as needed) as well as PRNs (as neededs) for anxiety with Vistaril and lorazepam.

The patient was described as withdrawn and isolative with paranoid ideations. There was no evidence of suicidal or homicidal ideation. He was said to be less perplexed than on admission but with continuing paranoid delusions. He was stated to have noticeable improvement in mood, eye contact, and participation in unit activities, while denying suicidal thoughts. By the date of discharge, he was stated to be feeling better, denying suicidal or homicidal ideation and with no agitation. 

No, the Continued Inpatient Mental Health Treatment was not medically necessary.
Essentials for a continued hospitalization include the diagnosis of a psychiatric disorder as defined by both the criteria of the American Psychiatric Association's Diagnostic and Statistical Manual (DSM)-5 (5). Among many others, these guidelines include as requirements:

1) The psychiatric disorder must be of such severity as to cause significant impairment of daily functioning in at least two important areas of the person's life such as work performance, social interactions, or family relationships.
2)  The treatment proposed must be relevant to the problems diagnosed and adjudged likely to benefit the patient.
3) Other available less restrictive treatment resources must have been considered and determined to be not available or not appropriate to the patient's needs or have been attempted and proven unsuccessful. Examples of less restrictive treatment resources would include, but are not limited to, residential treatment, day treatment, or intensive outpatient care.

With the application of these principles, inpatient psychiatric hospital treatment should be used only when necessary and avoided when other, more appropriate alternative treatments are available.

For the dates under review, it is not clear what the treatment rationale was that kept the patient in the hospital.  The patient had experienced significant improvement in psychotic symptoms and no longer evidenced dangerousness to self or others. The patient was compliant with treatment and there is nothing in these records to support the need for inpatient treatment for issues that could have been effectively managed at a lower level of care (1, 2, 3, 4). Therefore, based on the evidence-based literature, the inpatient stay on the dates of service in question cannot be established as medically necessary.