Appeal type: Medical necessity
Decision: Upheld

High Risk Suicide
Mental Health - Inpatient

Summary:
The patient is a male with a mood disorder and multiple substance use disorders who was admitted psychiatrically on an involuntary legal status to a hospital. 
The patient was seen in a local emergency room (ER) .and sent to this facility for psychiatric admission on a two physician certification involuntary hospitalization order (NY legal code 9.27) for treatment of worsened depression and suicidal ideation (SI) in the context of substance use. On admission to this facility the physician noted SI was "recurrent," that he had thoughts of cutting himself and his intent was "moderate." The patient has "polysubstance use disorder" but the specific substances he uses were not delineated by the admitting physician. He endorsed not taking his prescribed psychiatric medications (quetiapine, alprazolam, gabapentin) for two months and was restarted on all of them at the full previous doses without any documentation of medical decision making/rationale/indication. He was in a Methadone Maintenance Treatment Program (MMTP) taking 160 milligrams (mg) of methadone daily and this was continued. His admitting diagnosis is listed as major depression. He had no acute medical complaints and his admitting physical exam and vital signs were unremarkable other than he is obese.
He reported a history of numerous psychiatric hospitalizations. A complete psychiatric history was not included in the chart. More specifically there was not documentation of his history of mental health interactions, past diagnoses, past symptoms that led to those diagnoses, a broad lifetime psychiatric review of symptoms, past medication trials and responses, past response to psychotherapies, longitudinal history of SI, reasons for past admissions, etc. The admitting history and physical (H&P) does not include a differential diagnosis. Current depressive symptoms are documented but not findings that support "recurrent" major depression. The admitting physician documented that he had a suicide attempt in the last 6-12 months. The psychosocial assessment does not support this but lists that he has a history of "cutting wrist at 18 years old, OD." An exploration of circumstances, intent and degree of injury are not documented.
The admitting physician noted he was in an MMTP and that he has "polysubstance use disorder" but specifics on substance, method, amount, frequency and last use are not documented. The psychosocial assessment documents that he denied using opiates other than methadone currently and has been using cocaine every other day with last use two days prior.
He denied a family history of mental health conditions.
He is domiciled through an organization "Concern for Independent Living" and his housing was not at risk. He is unemployed. He endorsed a history of childhood physical and sexual abuse. He completed some college. He served time for drug related charges.
Medically he has asthma and obesity.

After admission he was put on his previous home meds at full doses. The admitting documented that the patient was already less depressed, not impulsive, and denying SI or homicidal ideations. The notes are similar. Each of these progress notes is 2-3 lines long without documentation of justification for continued stay. The source of information in these notes is also unclear. In other words, it is not clear if the physician obtained this information from nursing or chart review or direct interview of the patient. Nursing notes from this time period are unremarkable; there were no behavioral disturbances documented. By discharge his diagnosis is listed as bipolar disorder. However, notes from this portion of the stay do not document any clinical information, rationale or decision making that would lead to this diagnosis.

The daily progress notes from the physician during this portion of the stay continue to be about one to three lines in length which limits the depth of this review:

The patient is "feeling sad" but "contracting for safety." No SI or homicidal ideation (HI). The physician raised his Gabapentin without documenting an indication or rationale. This note is 2.5 lines long and does not contain a mental status examination (MSE).

This note is 1.5 lines long. There is no MSE section. The patient denied SI/HI and "mood is improving."

This note is 2 lines long. The patient denied SI/HI. He was "somewhat psychomotor agitated" but responding to "limit setting."

The patient was aware he was to be discharged this day. His SI reemerged and discharge was cancelled. The attending physician wrote less than 1.5 lines of texts. There was no risk assessment, no full progress note, no formulation, differential, or documentation of clinical rationale.

The patient again denied SI to staff but was telling staff he will "hurt himself." However, the physician also documented the patient was "looking forward" (i.e. future orientation) to inpatient rehabilitation after discharge. Again, a full progress note is not documented.

The patient's planned discharge was again cancelled because he was "feeling suicidal."
The patient was discharged. The hospital course notes that "his symptoms are suggestive of bipolar disorder" but a full differential and psychiatric review of symptoms was not documented.
Nursing and social work notes were also reviewed for this time period under review. They are also very brief and did not add significantly to this reviewer's understanding of the patient or his treatment. For example, occasionally nursing notes document that he is "preoccupied" or "less preoccupied" but this reviewer could find no documentation on what topic(s) patient was reportedly preoccupied. A nursing notation states that he is labile but there is no correlation in the physician's notes, and this is not expanded on. Other notes from the same day indicate he was appropriate. The social work note documents that the patient endorsed SI without plan to her, she told the physician and he cancelled the discharge. Again, there is no documentation of a risk assessment.
The subject under review is the medical necessity for the 9 units of inpatient mental health treatment.

The health plan's determination is upheld.

No, the 9 units of inpatient mental health treatment were not medically necessary for this patient. The chart submitted for review lacks basic elements of documentation that are the standard of care clinically and in terms of billing/reimbursement requirements for inpatient psychiatric care. From the information available the patient denied SI the day after admission and throughout his stay with the exception days he had been told he was going to be discharged. One note from social work documents that his SI was without plan. There was no documented risk assessment, formulation, or any other meaningful documentation of the physician's medical decision making including justification for continued care.  The patient denied SI but told peers he was having thoughts of "hurting" himself. Note that this does not necessarily imply suicidal intent. Staff also documented future oriented statements. There again was no risk assessment documented, no full progress note, so this reviewer's ability to interpret is limited. He again reportedly endorsed SI on a day of planned discharge. Again, this is not explored in the chart. Neither his admitting diagnosis of major depression recurrent or discharge diagnoses "suggestive" of bipolar disorder are explored in the chart; i.e. his diagnosis is uncertain based on the information that is included. There is no clinical discussion of differential diagnoses including the role drugs may be playing, past trauma, personality factors, or any possible secondary gain factors.
In looking at criteria for inpatient stay and generally accepted standards for psychiatric interview, diagnosis and treatment this submitted chart lacks basic elements that would justify ongoing inpatient stay. The very brief documentation of SI on the days of planned discharges is insufficient to justify continued stay based on danger to self. His diagnosis and psychiatric history is not well documented which calls into question whether ongoing inpatient treatment would be expected during this time to improve his condition. None of the physician notes document medical decision making around continued stay.