Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Anxiety/Depression
Treatment: Psychiatric Acute Inpatient 
The insurer denied: Psychiatric Acute Inpatient
The denial is: Upheld

The patient is a female who presented to the emergency department with weakness, anorexia and a 20-pound weight loss in three months with anxiety and depression. The patient was 14 weeks status post face and neck lift. She complained of a tightness in her throat and was afraid to swallow. Her outpatient psychiatrist had prescribed Prozac and Ativan, but she had an intolerance with the Prozac, and had a history of intolerance with selective serotonin reuptake inhibitors (SSRIs). She was medically screened and admitted for inpatient level psychiatric treatment with mood, anxiety, and trauma-related disorders. Her mood had recently worsened with increased anxiety, depression and sleep disturbance, as well as the weight loss associated with anorexia and dysphagia. The patient's functional capacity had declined, and she reported that she was afraid to eat. She had chronic medical conditions including gastroesophageal reflux disease (GERD) treated with omeprazole and a history of pulmonary embolus; she was also prescribed Linzess.

The patient was generally compliant with her treatment plan and mostly adherent with medications with ongoing concern that the medications were affecting her neck tightness. There were no complications of treatment otherwise, or complications of the clinical course during her inpatient stay. The patient was improved and functioning better with sleep and eating. She was noted to be persistently depressed and anxious though mood was improving, and anxiety had diminished. The patient was requesting referral for assisted living services due to her continued worry about her neck and swallowing capacity. Throughout the inpatient stay, she had denied suicidal ideation and there were no safety concerns. She was discharged with clinically appropriate aftercare including referral to Intensive Outpatient Program (IOP) level services for medication management and continued psychiatric care while residing in an assisted living facility. The subject under review is the medical necessity for the acute inpatient psychiatric stay.

The health plan's determination is upheld.

The requested health service/treatment of Psychiatric Acute Inpatient Care is not medically necessary for this patient for the denied dates of service.
Inpatient level treatment was not medically necessary in this case scenario. The patient could have received intensive mental health services with lower-level care in keeping with prevailing standards of medical practice. The residual symptoms of depression and anxiety did not require or warrant inpatient level structure, monitoring or intensity of services. Her husband was supportive and there were other treatment options to address the patient's somatic concerns that included dysphagia and fear of eating. The patient's psychosocial stressors were not so severe to prevent treatment from continuing at a lower level of care with more intensive services. The patient had access to continued treatment with medication and therapy, as clinically appropriate. Thus, the inpatient level mental health stay is not medically necessary in keeping with prevailing standards of medical practice.