Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Thoughts of suicide
Treatment: Continued Inpatient Mental Health Treatment
The insurer denied the Continued Inpatient Mental Health Treatment
The denial is upheld

The patient is a transgender female-to-male. He was reported to have been admitted to the acute inpatient behavioral health unit. He was diagnosed with bipolar disorder. The patient was reported to have been admitted for worsening symptoms of depression and suicidal ideations in the context of significant psychosocial stressors. The patient was reported to have had an argument and physical altercation with his aunt, following which he expressed suicidal ideations and was subsequently brought to the emergency room. He was also reported to have auditory hallucinations, delusional thoughts and paranoia at the time of his admission.

The request for continued acute inpatient behavioral health coverage was noted to have been previously denied as not medically necessary. Per the health plan, the patient was not reported to be at imminent risk of harming himself or others. He was not reported to have any other severe behavioral health problems that required inpatient treatment.

The patient was reported to have a significant history of behavioral health treatment in the past, including multiple inpatient psychiatric hospitalizations. Previous diagnoses indicated include bipolar disorder, posttraumatic stress disorder and borderline personality disorder. He was reported to have a history of self-injurious behaviors including superficial cutting. There was no indication of the patient had any history of suicide attempts in the past. He was reported to have a history of being subject to verbal abuse. There was no indication of the patient had any significant history of physical, emotional or sexual trauma. The patient was not reported to have any significant ongoing medical conditions that required hospital-based interventions or monitoring. The patient was reported to have a history of alcohol and cannabis abuse.

The patient had no significant ongoing medical problems that required hospital-based interventions or monitoring. He was not reported to have significant functional impairments including age-appropriate activities of daily living and self-care that represented a change from his baseline. The patient was not reported to have any significant adverse effects from any prescribed psychotropic medication. He was noted to be participating in treatment and largely compliant with unit routines. There was no significant deterioration or emergence of new psychiatric symptoms during the patient's stay on the inpatient unit. Continued inpatient hospitalization is evidenced to be largely related to placement issues and for custodial reasons. The patient's aunt was noted to have declined to take the patient back.

No, the Continued Inpatient Mental Health Treatment was not medically necessary.
Based on current peer-reviewed, evidence-based medical literature, the requested service (acute inpatient behavioral health stay) was not found to be medically necessary. The clinical information provided does not indicate that the service requested was the least restrictive setting that was medically necessary or likely to be successful in treating the patient's symptoms (1-8).

The patient is a transgender female-to-male who was reported to have been admitted to the acute inpatient behavioral health unit. He was diagnosed with bipolar disorder. The patient was reported to have been admitted for worsening symptoms of depression and suicidal ideations in the context of significant psychosocial stressors. The patient was noted to have been provided with individual, group and milieu therapy in addition to medication management while admitted to the acute inpatient psychiatric unit.

The patient was noted to be largely stable and at his baseline with no significant acute behavioral symptoms. Mental status examination was noted to be largely unremarkable. The patient was not reported to have any active suicidal or homicidal ideations with plans or intent (per progress notes and nursing evaluations). There was no indication of the patient was at imminent risk of harm to himself or others. He was not reported to have any symptoms suggestive of command hallucinations, persecutory delusions, or extreme paranoia. He was not reported to have any symptoms of mania or hypomania. He was not reported to have exhibited any significant agitation or aggression while on the inpatient unit. The patient was not in any self-injurious behaviors. There was no indication of the patient continued to express urges to engage in self-harm.

The patient had no significant ongoing medical problems that required hospital-based interventions or monitoring. He was not reported to have significant functional impairments including age-appropriate activities of daily living and self-care that represented a change from his baseline. The patient was not reported to have any significant adverse effects from any prescribed psychotropic medication. He was noted to be participating in treatment and largely compliant with unit routines. There was no significant deterioration or emergence of new psychiatric symptoms during the patient's stay on the inpatient unit. Continued inpatient hospitalization was evidenced to be largely related to placement issues and for custodial reasons. The patient's aunt was noted to have declined to take the patient back.

The patient may have been treated safely and effectively in a less restrictive setting and lower level of care. Therefore, continuing inpatient hospitalization was not found to be medically necessary.

Yes, the health plan did act reasonably, with sound medical judgment, and in the best interest of the patient.
Clinical information reviewed indicates that the patient was largely stable and at his baseline. Continued acute inpatient psychiatric hospitalization is evidenced to be largely related to placement issues and for custodial reasons. The patient was not noted to be at imminent risk of harm to himself or others. There was no indication of the patient had any significant ongoing symptoms of psychosis or mania. There was no indication of the patient had any ongoing medical conditions that required interventions or monitoring. He was not reported to have any significant functional impairments including age-appropriate activities of daily living and self-care that represented a change from his baseline. The patient may have been treated safely and effectively in a less restrictive setting and lower level of care such as a day treatment program. Therefore, the health plan was noted to have acted reasonably and with sound medical judgment, in the best interest of the patient.