Appeal type: Medical necessity
Decision: Overturned

  
Diagnosis: Depressive Disorder

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission. The denial is reversed.

This patient is a female who was admitted inpatient mental health treatment after a suicide attempt by taking 60 Benadryl pills and having a subsequent seizure. The patient reported severe depressive symptoms including depressed mood, suicidal thoughts, anhedonia, poor energy, concentration problems, and guilt. The patient's history was significant for suicide attempt by cutting self. The patient had a diagnosis of Depressive Disorder. The patient had multiple stressors including poverty, victimization of bullying, lack of supports, adverse childhood events, and disrupted attachments. The patient was started on Fluoxetine during her inpatient stay, and the medication was increased several times due to continued depressive symptoms. The patient was transferred to the adolescent unit with 1:1 observation. A 72 hour letter reportedly was submitted and she was discharged.

The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Suicidal Behaviors reports that patients with suicidal intent or plan or attempts are in need of inpatient treatment. It also reports that patients with past suicide attempts are at high risk for suicide. In this case, this patient had a very serious suicide attempt by taking 60 Benadryl pills with intent to die and she had a seizure on way to the hospital. The patient also had a past suicide attempt less than a year ago by cutting, which put this patient at high risk for suicide. The patient continued to report severe depressive symptoms including depressed mood, suicidal thoughts, low energy, isolation, and during her inpatient stay, the patient required multiple changes to her anti-depressive medications to appropriately treat and stabilize her symptoms.

Notes reported that the patient was started on Fluoxetine for depression. Other notes reported that the patient's Fluoxetine had to be increased due to continued significant depressive symptoms including dysphoric mood, suicidal thoughts, and low energy. The patient was noted to be lying in bed, exhibiting social isolation and withdrawal, poor participation, and irritable mood. Still other notes reported that the patient's Fluoxetine again had to be increased to 30 mg per day for continued depressive symptoms. Notes reported that the patient's Fluoxetine was then again increased to 40 mg per day to target continued depressive symptoms. Subsequent notes reported that the patient was transferred to the adolescent unit with 1:1 observation and precautions for her sexual acting out. Notes reported that a 72 hour letter was submitted and the patient was discharged.  

Based on the review of the medical record, this patient was a high risk patient for self-harm and danger. The patient was admitted with a serious suicide attempt, and during her inpatient stay, her depressive symptoms were difficult to control with anti-depressant medication. The patient also required 1:1 observation and precautions for sexually acting out and affecting other peer patients.  Given this patient's psychiatric history as well as her persistent unstable symptoms and behavioral activity, continued inpatient stay was medically necessary to treat this patient's medical condition. 

The health plan did not act reasonably with sound medical judgment, and in the best interest of the patient.

The carrier's denial of coverage for the inpatient admission should be reversed. The medical necessity is substantiated.