Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Bipolar disorder.
Treatment:  Inpatient admission.
The insurer denied the continued inpatient admission; the denial is overturned.  The Continued Inpatient admission was medically necessary.

The patient is a female with a history of mental illness and substance abuse, who received inpatient psychiatric hospitalization.

The patient has been diagnosed with mental illness.  There is a diagnosis of Bipolar Disorder.  There is a prior history of suicide attempt by overdose, as well as prior psychiatric hospitalization.  The patient has a history of alcohol abuse including a recent relapse after six months of sobriety.  The patient was living with her son and boyfriend.  She has a family history of serious mental illness, including mother and grandmother with bipolar, and a father with substance abuse and depression.  The patient has a history of outpatient psychiatric treatment and was treated with Latuda and Cymbalta in the outpatient setting.

The patient self-referred for psychiatric treatment with symptoms of severe depression, hopelessness, helplessness.  She was medically cleared for inpatient psychiatric hospitalization and was admitted for inpatient psychiatric treatment.  She was treated with individual and group treatment.  She was treated by a multidisciplinary team, including psychiatry, nursing, and therapy staff.  She received a psychopharmacology evaluation and Latuda was stopped.  Cymbalta was increased to 60mg per day.  Wellbutrin was started at 150mg daily, and Lithium was started, as well.  Trazodone was started, as well, and Vistaril was used as a prn (as needed).  

The patient was noted to have poor sleep the previous night with ongoing hopelessness.  

Trazodone was discontinued and Remeron was started.  

Remeron was discontinued, and Sonata was started at 10mg at night with Wellbutrin decreased to 100mg daily.

The patient was discharged from the inpatient unit with a plan for ongoing follow psychiatric up.

The patient represented an acutely elevated risk of dangerous behaviors, and there was no less-restrictive treatment environment appropriate.  The acute risk factors of mood disorder with the chronic risk factors of potentially dangerous behaviors suggest that the patient would have been at an acute risk of self-injurious behaviors (including but not limited to suicide) were she to have been discharged from the inpatient hospital setting.  The patient was discharged from the inpatient psychiatric hospital setting as soon as a less-restrictive treatment setting was appropriate.  

The patient represented an elevated risk of dangerous behaviors including self-injury, and suicide, and there was no less-restrictive treatment environment appropriate.  Therefore, the treatment was medically necessary.  While the patient was not endorsing active suicidality or homicidality, the patient remained with acute mood symptoms.  The patient had multiple static risk factors for potentially dangerous behaviors, including prior suicide attempts, substance abuse, and diagnosis with a severe mental illness.  Therefore, the patient represented a chronic risk of potentially dangerous behaviors.  The fact that patient remained depressed with ongoing medication changes was an acute risk factor for dangerous behaviors.  Furthermore, the fact that there was no less-restrictive environment of care appropriate suggests that ongoing inpatient psychiatric hospitalization was medically necessary and should be covered by the patient's health plan.