Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Mental Health 
Treatment: Mental Health Inpatient
The insurer denied: inpatient mental health treatment
The denial is: Upheld in whole

The patient is a female who was admitted  for suicidal and homicidal ideation. The patient also had a recent hospitalization.  There are noted to be parent-child relational issues.  The patient had also been skipping school and had urges to cut her arms.  The patient was diagnosed with major depressive disorder (MDD), recurrent, severe.  The patient was medicated with Lexapro 15 milligrams (mg) at hour of sleep (qHS) and Clonidine 0.1mg on admission.  There is noted to be a history of trauma and long standing relational issues with mom.

The patient was admitted and initially vacillated between saying that she could not be safe if she discharged anywhere other than her father's home to saying that she was ready to go. Hydroxyzine 25mg three times per day (TID) as needed (PRN) for anxiety was added around the time of admission.

The patient had variable appetite, but no safety concerns.  The patient was not suicidal, homicidal, or psychotic. The patient was attending groups.  She talked to mother on the phone intermittently and was agreeable to going to the community residence.
The patient's mom had concern for the patient being discharged home due to potential for self-harm.  The patient did have some increased urges to self-harm and scratched herself the day prior when feeling overwhelmed.  She was able to process with staff.  The patient had no active suicidal ideation with plan, homicidal ideation with plan or command hallucinations.  She did state that she did not know if she could be safe if she returned to live with mom.  The Community residence referral was under review at that time.

For the remainder of the patient's stay, through discharge mom continued to think the patient needed to stay on the unit while awaiting placement.  The patient attended groups.  The patient was not suicidal, homicidal, psychotic, self-injurious or threatening.  She had adequate sleep and hygiene.  The decision was made to discharge the patient home while awaiting placement.  There was a safety plan made and the patient stated that she would follow the plan.

The health plan's determination is upheld in whole.

Based on the recommendations from American Academy of Child and Adolescent Psychiatry (AACAP), children and adolescents should be treated in the least restrictive environment.  During the time under review the patient was medication compliant and euthymic.  The patient had no active suicidal ideation with plan, homicidal ideation with plan or command hallucinations. The patient was not physically aggressive, acutely manic, or sexually inappropriate. The patient was not catatonic. The patient had no significant medical instabilities. The patient had no required emergency medications, restraints, or seclusions.  The patient was attending and participating in groups. The patient had adequate sleep and appetite for the most part. There was no indication for around the clock monitoring and the request for continued stay was due to placement. Though the patient made some statements that she could not stay safe at her mom's, there was no specific plan or intent to harm herself or others.  There was no imminent risk noted throughout the remainder of her stay.  Treatment could have been addressed at a lower level of care.