Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Unspecified schizophrenia
Treatment: Continued Inpatient Mental Health Services
The insurer denied the continued inpatient mental health services.
The denial is overturned.

The case involves an adult female diagnosed with unspecified schizophrenia. She was admitted to acute inpatient level services after presenting to the emergency department with severe symptoms reflecting an exacerbation of the chronic psychotic disorder. She had stopped her psychotropic medications and was lost to follow-up with her outpatient providers. Her presentation to the emergency department included bizarre behavior and impulsive aggression with grossly disorganized thought content.

The patient has a history of schizophrenia and psychiatric treatment, including multiple hospitalizations and use of long-acting injectable antipsychotic medication. She did not have a history of suicidal or self-harming behavior.

There were no acute general medical issues in this case, though the patient had presented with chronic medical conditions that included hypertension, diabetes mellitus and chronic bronchitis. Medical screening in the emergency department was unremarkable or normal.

Mental Status Examination on admission: The patient was agitated with poor eye contact and mental confusion. She was uncooperative, guarded and hypervigilant, with irritable mood and anxiety. She had decreased concentration, energy, appetite, sleep, and volition. Her speech was rapid and illogical, with disorganized thought processing. She denied suicidal ideation or aggressive impulses despite her presentation with hostility, anger, tension, and excitability. Insight and judgment were limited and impaired, and she had poor control of impulses. 

The patient is single, homeless, unemployed, and disabled. She had no social supports. There were no legal issues or trauma history in this case.

The patient was admitted to acute inpatient level care after medical screening in the emergency department, as noted. The patient's treatment plan included safety and resumption of medication to address an exacerbation of the chronic psychotic disorder. The patient remained acutely psychotic, requiring frequent re-direction and safety monitoring. She was started on Depakote and risperidone, titrated as clinically appropriate together with as needed (PRN) medications for anxiety, agitation, and insomnia including trazodone. General medical consultation was provided and she had laboratory assessment, an electrocardiogram (EKG), and chest x-ray that were abnormal with first degree atrioventricular (A-V) block, hypertrophy of the left ventricle, and a granuloma of the right lung. She refused a computed tomography (CT) scan of the chest.  

The patient remained with persistent symptoms of psychosis that were slowly improving in response to her medications; she continued to display poor attention to self-care with continued evidence for impaired insight and judgment. Medications were titrated as clinically appropriate, with an injection of Risperdal Consta with plans for continued use. The treatment included efforts to address the lack of insight (anosognosia) and risk for medication non-adherence with psychoeducation and encouragement to attend groups focusing on social skills and relapse prevention.

The patient showed improved functioning, she had been increasingly cooperative with staff, and continued to be medication adherent; she was able to receive psychoeducation with discharge planning with assistance of the case manager. By the time of discharge, the patient was approaching baseline with goal directed thought and improved mood and functioning with activities of daily living (ADLs). Her medications had effectively addressed the exacerbation and acute symptoms of schizophrenia that had persisted. Case management developed a safe and clinically appropriate discharge plan with plans for follow up with community providers and referral to a women's shelter. The patient reported feeling better and denied suicidal ideation, morbid thoughts, or perceptual disturbance. Mood was okay. Sleep and appetite were okay.  She did continue to have minimal interaction with peers and did not attend group sessions, staying in her room during much of the stay. Discharge occurred with clinically appropriate aftercare in collaboration with community providers to include mental health services with a safety plan, as well as recommendations to address the general medical conditions.

Yes, the proposed treatment is medically necessary for this patient.

The admission and the continued inpatient stay for the dates of service under review could not have been safely or effectively provided at a lower level of care. Thus, the requested benefit of the inpatient stay for mental health treatment through discharge is reasonable, clinically appropriate, and is consistent with prevailing standards of medical practice for the treatment of the condition diagnosed in this case. Medical necessity is met, which means or describes a health care service that a health care Provider, exercising his/her prudent clinical judgment, would provide to a Covered Person for the purpose of evaluating, diagnosing, or treating an illness, injury, disease, or its symptoms and that is: in accordance with the generally accepted standards of medical practice; clinically appropriate, in terms of type, frequency, extent, site and duration, and considered effective for the Covered Person's illness, injury or disease; not primarily for the convenience of the Covered Person or the health care Provider; and not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that Covered Person's illness, injury, or disease. "Generally accepted standards of medical practice", as used above, means standards that are based on: 1) credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community;  2) physician and health care Provider specialty society recommendations; 3) the views of physicians and health care Providers practicing in relevant clinical areas; and 4) any other relevant factor as determined by the independent expert reviewer assigned to this New York mandated case review.

The patient's continued symptoms of schizophrenia together with continued risk of erratic and unsafe behavior, as well as issues with non-compliance with treatment prompted the necessity for the admission and warranted the continued acute inpatient level structure and monitoring through discharge when the patient was nearing her baseline functioning. The case is complicated by severe psychosocial stressors (homelessness and a lack of support), non-compliance with treatment, and medication adherence problems. The residual symptoms of the chronic psychotic disorder, risk for erratic behavior or response to continued disturbance of thought and reality testing, and treatment issues related to non-compliance/non-adherence with medications, and the need for arranging a safe and clinically appropriate discharge plan all warranted the acute inpatient level services to include safety monitoring and assistance with activities of daily living (ADLs). The continued inpatient stay through discharge was therefore clinically appropriate and medical necessary in order to provide the necessary and the continued inpatient level structure and 24-hour monitoring through the day of discharge when the patient had reached a level of stability such that she could return to the community with the arrangement of outpatient level services and with clinically appropriate follow-up and aftercare, as well as referral to a women's shelter where she would receive social supports.

The patient's acute symptoms of schizophrenia together with continued risk of impulsive or erratic behavior and safety concerns, as well as the presenting feature of non-compliance with treatment, prompted the necessity for the continued acute inpatient level structure and monitoring through discharge. The acute symptoms of psychosis, risk for problematic or unsafe behavior, and treatment issues related to non-compliance/non-adherence with medications, and the need for arranging a safe and clinically appropriate discharge plan, warranted the admission and continued services at an acute inpatient level of care to include safety monitoring and medication monitoring. The continued inpatient stay through discharge was therefore clinically appropriate and medically necessary in order to provide the necessary and the continued inpatient level structure and 24-hour monitoring through the day of discharge when the patient had reached a level of stability that she could return to the community with outpatient level services, housing, and with clinically appropriate follow-up and aftercare.

These answers are consistent with prevailing standards of care and the scientific literature and guideline, referenced below, and is in keeping with New York State instruction for this medical necessity review.