Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Depression; Anxiety
Issue under review: Inpatient admission

Determination:
The Inpatient admission was medically necessary.

The patient is an adult male with a history of mental illness who received inpatient psychiatric treatment at the hospital.

The patient has a history of mental illness including diagnosis of depression and anxiety.  He had previously been evaluated in the emergency room for symptoms of anxiety and a panic attack.  There is a medical history of diabetes mellitus, obesity, and high blood pressure.  There is no prior history of psychiatric treatment and no outpatient treatment providers in place.

On the dates of admission, he presented with a family member to the emergency room for evaluation.  He was noted to have depression and anxiety with poor appetite, inability to sleep and "no drive."  He was noted to be scared and withdrawn.  There was impaired reality testing, and he was noted to have had "blood glucose levels running high."  He was evaluated by a psychiatrist who recommended inpatient psychiatric hospitalization.  He was admitted with a diagnosis of Major Depressive Disorder, Single Episode, Severe.  

On the unit, the patient was treated by a multidisciplinary team including nursing, psychiatry, and therapy staff.  He received individual and milieu treatment.  He received a psychopharmacology evaluation and was treated with Mirtazapine 15mg PO (by mouth) QHS (nightly) and Lorazepam as a PRN (as needed) medication.

The following day, the patient's family arrived and the patient and his family requested discharge.  He was noted to be safe for discharge and was released from the inpatient unit with a plan to follow up in the outpatient setting.

The patient represented an acutely elevated risk of dangerous behaviors, and there was no less-restrictive treatment environment appropriate.  The acute risk factors of inability to function as well as depression and anxiety with the chronic risk factors of potentially dangerous behaviors suggest that the patient would have been at an acute risk of self-injurious behaviors (including but not limited to suicide) were he to have been discharged from the inpatient hospital setting.  The patient was discharged from the inpatient psychiatric hospital setting as soon as a less-restrictive treatment setting was appropriate.  

The patient represented an elevated risk of dangerous behaviors including self-injury, and suicide, and there was no less-restrictive treatment environment appropriate.  Therefore the treatment was medically necessary.  While the patient was not endorsing active suicidality or homicidality, the patient remained depressed, anxious and had demonstrated inability to function in the outpatient setting.  The patient had multiple static risk factors for potentially dangerous behaviors including depression, medical illness, and diagnosis with a severe mental illness.  Therefore the patient represented a chronic risk of potentially dangerous behaviors.  Furthermore, the fact that there was no less-restrictive environment of care appropriate suggests that ongoing inpatient psychiatric hospitalization was medically necessary and should be covered by the patient's health plan.