Appeal type: Medical necessity
Decision: Overturned

Mental Health - Depression
Mental Health - Inpatient

The patient is a male admitted for acute inpatient psychiatric treatment. The patient had become increasingly paranoid thinking that he was being poisoned with carbon monoxide gas, and that the police were going to arrest him. He had worsened over a two-month time frame with worsening symptoms of depression despite treatment in the community and a previous psychiatric hospitalization. He had worsened prior to admission in the context of a decline in functioning including basic activities of daily living. He was calling the fire department to check his house for gas and was calling emergency services reporting that his wife was gravely ill with morbid preoccupations. 

The patient's mental status examination revealed a cooperative but guarded man with depressed mood and depressive ruminations. He had only fair eye contact, was soft spoken and had slow speech. He was anxious with apprehension, tension, sleep disturbance and excessive worry, as well as motor retardation and slowed mentation with disorganized thought processing and thought blocking. He reported morbid thoughts with regard to the paranoid delusions, as noted and was responding to internal stimuli due to vague auditory hallucinations. There was no evidence for mania, formal thought disorder, or suicidal ideation. He denied homicidal ideation or aggressive impulses. Sleep, appetite, energy levels, concentration, and volition were disturbed, and he reported a persistent headache and fatigue. 

He was placed on close observation, structured milieu therapy, and resumption of pharmacotherapy with Prozac and risperidone. Group and individual psychotherapy were provided as well as other therapeutic interventions to facilitate better coping and functioning, and improved reality testing. The patient remained depressed with psychotic features. He was socially withdrawn and isolated himself. Risperidone was stopped and Seroquel was started together with the Prozac. A neurology consult was provided to rule out Lewy Body Disease. 

The patient's Seroquel was titrated. Case management was working with the patient and family with discharge planning. He gradually participated in group and milieu therapies. Family focused sessions were occurring with focus on a discharge plan and clinically appropriate disposition. The patient's mood was described as neutral and improved with diminished anxiety and better functioning. Speech was clear and goal directed. Medications had been adjusted with tolerability. His insight was improved and judgment intact allowing for discharge with plans for outpatient aftercare and continued use of Prozac and Seroquel.

The health plan's determination is overturned.

The patient's continued acute inpatient mental health treatment through discharge was clinically appropriate, reasonable, and in the best interest of the patient as noted in the answer to question 1; he had severe symptoms of depression, he was a safety risk with delusional thinking, and outpatient treatment had failed to prevent the worsening symptoms of depression with onset of severe symptoms in the context of severe psychosocial stressors and a decline in functioning. The patient remained symptomatic and functionally impaired with high risk for relapse if discharged from acute inpatient level care; and the patient needed to reach a stable baseline of functioning with assurance of medication tolerability with a solid disposition and safety plan prior to discharge from inpatient level care. 

Thus, it was medically necessary for this patient with major depressive disorder to remain in the acute inpatient setting in order to continuously assess his response to treatment and ability to function, and to address the acute risks of a return to the community with the noted functional impairments and treatment issues, as well as the need to develop a safe and clinically appropriate discharge plan and disposition with clinically appropriate aftercare.