Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Major depressive disorder, post-traumatic stress disorder (PTSD), obsessive compulsive disorder (OCD), and generalized anxiety disorder 
Treatment: Continued inpatient mental health admission 

The insurer denied the continued inpatient mental health admission. The denial is upheld. 

No, the proposed treatment was not medically necessary. 

The patient is a female with diagnoses of major depressive disorder, post-traumatic stress disorder (PTSD), obsessive compulsive disorder (OCD), and generalized anxiety disorder who was admitted under mental health arrest due to suicidal ideation nine days after discharge from a residential treatment program. She also had a history of self-injury by scratching herself with her fingernails. The patient's clinical presentation throughout her stay was highly suggestive of a severe cluster B personality disorder. Although there was no actual documented history of true suicide attempts, the patient reported virtually continual suicidal ideation, usually with plans such as choking herself with a blanket or by head-banging. She had poor boundaries, engaged in behaviors which were destructive to other patients' treatment plans, and indulged in staff splitting. Her frequent statements regarding suicidality were evasive and ambiguous. 

The treatment team acknowledged the patient's chronic thoughts of self-harm but recognized her ability to keep herself safe by reaching out for support. Discharge was planned for later that week. However, at another meeting, the patient's mother expressed concern about the patient's safety at home and requested a second opinion. The patient wanted to change her location on the unit, feeling that she could not communicate with her treatment team. The treatment team yielded to this apparent splitting behavior, and the decision was made to transfer the patient's care to a different treatment team where she remained on 15 minute checks. 

The patient went home on a pass "so that she can better assess her risk of lethality and readmission." The patient continued to report suicidal ideation and was evaluated for electroconvulsive therapy (ECT). She reported increased suicidal ideation after her first session. The patient asked for ECT to be continued. She stated that her goal was to be discharged by the end of the month, but she had refused ECT stating that she did not think it was working and was experiencing side effects as well as increased suicidal ideation. 

The team pointed out to the patient the contradiction in her commitment and her persistence in continuing her schoolwork with college plans while at the same time being persistent in reporting suicidal ideation.

Another change in unit location was made due to the patient's issues with boundaries and her giving other patients advice that contradicted their treatment plans. Discharge was planned for at the patient's request.  The patient stated she planned to stay with her father upon discharge. She was discharged on that date with an extensive safety plan. 

The patient presented chronic suicidal ideation which was vague and devoid of specific lethal plans or intent. There was no documented history of true suicidal behavior. The patient generally expressed plans which were at most para-suicidal in nature. The patient's clinical presentation at discharge was no different than it was at the time of admission and reflected an inability to benefit from the current level of care. The treatment team's agreeing to the patient's and possibly her mother's requests was not in the best interest of the patient. Nothing in the documentation reviewed indicates that this patient's treatment could not have been carried out equally safely and effectively in a less intensive setting.