Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Unspecified Psychotic Disorder

Treatment: Inpatient hospital level of care

The insurer denied coverage for the inpatient hospital level of care.

The denial is overturned.

This is the case of an adult male who was transferred to the psychiatric unit due to acute psychotic symptoms. He reportedly had auditory and visual hallucinations, internal preoccupation, talking to self, delusions of grandiosity and persecution, disorganized and illogical thinking, laughing inappropriately, bizarre affect and behavior, lack of activities of daily living (ADLs) including not showering or brushing his teeth in 23 days, agitation, low frustration tolerance, verbal abuse, withdrawn behavior, poor insight and judgment, and noncompliance including not taking medications. He was sent to the hospital from the correction facility. The patient had past psychiatric hospitalizations. He had past reported suicidal ideation. He had a diagnosis of unspecified psychotic disorder. He was treated with oral Haldol and Haldol Decanoate. The patient improved and was discharged.
  
The American Psychiatric Association (APA) Practice Guidelines for the Assessment and Diagnosis of Patients with Schizophrenia Spectrum and Other Psychotic Disorders reports that patients with hallucinations, delusional thinking, disorganized thinking or behavior, severe agitation, aggression, suicidal or homicidal intent or plan, or inability to adequately care for basic needs are in need of hospital treatment. Also, the Milliman Care Guidelines (MCG) Behavioral Health Inpatient Level of Care Adult criteria reports that a patient needs to present as an imminent danger to self, imminent danger to others, with severe psychiatric or behavioral symptoms, have a severely dysfunctional living including inability to care for self, unwillingness to participate voluntarily, or a less restrictive level of care is not feasible to meet criteria for inpatient behavioral health level of care. 

This patient had severe psychiatric symptoms interfering with the ability to care for his basic needs and had acute psychotic symptoms requiring 24-hour hospital treatment. On admission, he reportedly had acute psychotic symptoms including auditory and visual hallucinations, internal preoccupation, talking to self, delusions of grandiosity and persecution, disorganized and illogical thinking, laughing inappropriately, bizarre affect and behavior, lack of ADLs including not showering or brushing his teeth in 23 days, agitation, low frustration tolerance, verbal abuse, withdrawn behavior, poor insight and judgment, and noncompliance including not taking medications. He took antipsychotic medication including oral Haldol and intramuscular (IM) Haldol Decanoate and it was reported that he was in restraints. Notes reported that he still had psychotic symptoms including bizarre affect, auditory and visual hallucinations, poor insight, and judgment, and initially refused labs and electrocardiogram (EKG). Later notes reported that he was still refusing medications and tried to elope and still had bizarre affect and behavior. Later notes reported that he refused medications, was bizarre, and had illogical thought process still. Later notes reported that he still had auditory and visual hallucinations, bizarre affect and behavior, poor insight, and judgment. He still had acute psychotic symptoms requiring 24-hour hospital treatment. He required a day of observation without psychotic symptoms before safely being discharged. The patient was discharged.

It did not appear that the health care plan acted reasonably, with sound clinical judgment, or in the best interests of the patient. The admission was appropriate as the medical records provided enough specific evidence to support that he required 24-hour hospital treatment. 

The insurer's denial of coverage for the inpatient level of care is overturned. Medical necessity is substantiated.