Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Schizoaffective Disorder.
Treatment: Inpatient mental health stay.
The insurer denied the inpatient mental health stay.
The determination is overturned.

The patient was admitted to acute inpatient psychiatric services for an exacerbation of a chronic psychotic disorder best characterized as schizoaffective disorder or undifferentiated type schizophrenia. The patient had shown increasing symptoms of psychosis following discontinuation of her oral medication with the onset of bizarre delusions and erratic behavior, disorganized thoughts with paranoid thinking together with motor agitation, and increasing responses to internal stimuli that included auditory hallucinations. She was brought to the emergency department by emergency services and was subsequently admitted after medical clearance that included a physical examination, laboratory assessment and drug screen. Her assessment included no abnormal or remarkable laboratory findings including a negative drug screen consistent with her history. She was noted to have a sickle cell trait.
The patient has a history of psychiatric treatment, including multiple psychiatric hospitalizations, but no report of suicidal behavior. There are no substance-related disorders in this case and no acute general medical issues. The patient had been involved with the assertive community treatment (ACT) team with use of Abilify and Abilify Maintena.
On Mental Status Examination on admission, the patient was psychotic and cognitively impaired with thought blocking, clear speech, racing and disorganized thoughts and response to internal stimuli. She was guarded and only superficially cooperative with poor eye contact. She displayed motor agitation with irritable and dysphoric mood. Insight was limited and judgment impaired. She denied suicidal ideation or aggressive impulses despite the recent bouts of aggression, and did not show evidence for overt features of mania or severe cognitive impairment (delirium or dementia) despite having poor attention and concentration due to the internal stimuli and mental confusion and distractibility with the disorganized thought patterns with tangential thought production. She reported auditory hallucinations with paranoid themes.
The patient was single and domiciled with her mother, and unemployed/disabled with government subsidies. There were no legal issues.
The patient's treatment plan included safety monitoring and medication targeting mood disturbance and psychosis, as well as the opportunity for therapy and psycho-education provided in the therapeutic milieu. The patient was variably cooperative but guarded and refused some of her medications during the initial week of her inpatient stay. The patient continued to display severe symptoms of psychosis with essentially little change in her mental status examination, and continued response to auditory hallucinations. She had received risperidone with an injection of Invega Sustenna, and there were plans for continued use of Invega Sustenna with tapering of the oral antipsychotic medication with Cogentin supplementation, as well as as needed (PRN) use of Haldol and Ativan for agitation and Benadryl and trazodone for insomnia.
She continued to display guarded behavior but was increasingly calmer and more socially appropriate with participation in groups and milieu activities focusing on social skills, reality testing and illness recovery. Again, the patient gradually became more at ease and was more receptive to participating in educational groups and other group sessions focusing on social skills with ongoing monitoring and development of a relapse prevention plan focusing on medication compliance/adherence. She received a second injection of Invega Sustenna with plans for continued treatment in the community with assertive community treatment (ACT level treatment) and return home. Case management was involved in developing a safe and clinically appropriate discharge plan with the resumption of ACT level treatment and referral to a sickle cell clinic. She was discharged, at which time she was no longer deemed to be a danger to herself or others and had resolved her auditory hallucination and paranoid thinking with improved mood and diminished anxiety and better control of impulses and better ability to comply with treatment.
 The health plan documents and appeal letters were reviewed, as well as case records and correspondence from the health plan and the treatment facility. The health plan level of care guidelines/medical necessity criteria were reviewed, as submitted. The dates under review were denied certification of coverage by the health plan for inpatient level treatment on the basis of medical necessity criteria. This case is a New York State mandated review. The issue under review is the medical necessity of continued inpatient mental health stay.
The patient's continued hospital stay for treatment of an exacerbation of a chronic psychotic disorder (schizophrenia spectrum disorder) associated with non-adherence and non-compliance with outpatient treatment and risk for aggressive behavior did warrant the continued stay through discharge. The patient's severity of symptoms, and the treatment refractory nature of her psychotic disorder, as well as the patient's inability to benefit from treatment at a lower level of care, functional decline, and safety issues related to persistent symptoms of psychosis, were clinical factors and treatment dimensions that warranted the continued acute inpatient hospital care, structure, and monitoring as proposed through discharge.
The medication changes and adjustments and safety monitoring together with attention to the compliance issues in this case were medically necessary in this case scenario; the intensity of services and safety issues related to erratic behavior and affective instability could not have been effectively addressed or managed at a lower level of care during the time interval under review.
The additional treatments were medically necessary in order to continued active treatment that included medication administration, evidence-based psychosocial therapy and other therapeutic interventions to address reality testing and social skills, to develop a safe and clinically appropriate discharge plan and disposition, and, to monitor the response to medication including the work with community providers for a step down to ACT level care and continued use of a long-acting injectable antipsychotic medication that were clinical factors and treatment dimensions that did require the continued inpatient mental health stay as requested. Thus, medical necessity is met. These answers are consistent with the scientific literature and practice guideline, referenced below, as well as prevailing standards of medical practice and NY State instruction for this review.