Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Disruptive Mood Dysregulation Disorder.
Treatment: Inpatient Mental Health Stay.
The insurer denied the Inpatient Mental Health Stay
The determination is upheld.

The patient was admitted to the mental health (MH) inpatient level of care due to a suicide attempt by overdose on 20 pills of Lasix. The patient has a history of suicidal behaviors, attempts and previous inpatient admissions. The request is for continued stay. The patient is diagnosed with disruptive mood dysregulation disorder (DMDD), post-traumatic stress disorder (PTSD). His grandmother is the patient's legal guardian. The patient is a transgender female to male. Child Protective Services (CPS) became involved due to allegations of abuse by his grandfather.
The patient had intermittent suicidal ideation, reports of auditory and visual hallucinations of anime characters intermittently, but it is noted this is more chronic than acute. The patient was noted to be provoking peers on the unit. The patient was medicated with Clonidine 0.1 mg three times per day (TID), Zoloft 200 milligrams (mg) daily and Vistaril 25 mg nightly at bedtime. The patient had been accepted to for state psychiatric admission, but no transfer date had been identified. The clinical team was also considering residential placement the following day and the patient's home was noted to be a trigger for his symptoms.
The patient was noted to be irritable, and punched a peer in the face. The patient did not require emergency medications, restraint or seclusions. The patient declined by mouth (PO) medications.
The patient had some agitation, intermittent passive suicidal ideation, no plan or intent. The patient had a PRN (meaning as needed or as the situation arises) of Vistaril. The patient had no self harm over the previous week. The patient had intermittent auditory and visual hallucinations of anime characters, but no command in nature.
The patient was noted to have very poor frustration tolerance, was manipulative and had very limited insight. The patient was oppositional and argumentative, provoking peers and getting into other people's conflict. This appeared more chronic than acute. Thought processes were organized. The patient has been accepted to the state hospital and was number 4 on the waiting list. The patient was also screened for residential treatment.
The patient was dismissive, negative and irritable. The patient had no active suicidal ideation with a plan, homicidal ideation with a plan or command hallucinations. The patient was not physically aggressive, acutely manic or sexually inappropriate. The patient had no significant medical instabilities. The patient had no required emergency medications, restraints or seclusions. The patient is compliant with medications.
The patient was generally calmer. The patient had intermittent urges to engage in self harm and did engage in scratching once, but did not require medical attention. The patient had no active suicidal ideation with plan, homicidal ideation with plan or command hallucinations. The patient was not physically aggressive, acutely manic or sexually inappropriate. The patient had no significant medical instabilities. The patient had no required emergency medications, restraints or seclusion. The patient was compliant with medications.
The patient was agitated and threatening. The patient did not respond to redirection and required intramuscular (IM) medication. The patient had no active suicidal ideation with plan, homicidal ideation with plan or command hallucinations. The patient was not physically aggressive, acutely manic or sexually inappropriate. The patient had no significant medical instabilities.
The patient was number 1 on the waiting list for state hospitalization. The patient had no active suicidal ideation with plan, homicidal ideation with plan or command hallucinations. The patient was not physically aggressive, acutely manic or sexually inappropriate. The patient had no significant medical instabilities. The patient had no required emergency medications, restraints or seclusion. The patient is compliant with medications.
The patient remained in behavioral control. He continued to have limited insight. The patient continued to be irritable and intermittently provoking behaviors. The patient had intermittent urges to engage in self harm, but did not engage. The patient had no active suicidal ideation with plan, homicidal ideation with plan or command hallucinations. The patient was not physically aggressive, acutely manic or sexually inappropriate. The patient had no significant medical instabilities. The patient had no required emergency medications, restraints or seclusions. The patient was compliant with medications. At issue is the medical necessity of inpatient stay.

Inpatient level of care was not medically necessary. The patient appeared to be nearing a baseline. The patient remained in behavioral control. He continued to have limited insight. The patient continued to be irritable and intermittently provoking behaviors. The patient had intermittent urges to engage in self harm but did not engage other than some scratching behaviors that did not require medical attention. The patient had no active suicidal ideation with plan, homicidal ideation with plan or command hallucinations. The patient was not physically aggressive, acutely manic or sexually inappropriate. The patient had no significant medical instabilities. The patient had no required emergency medications, restraints or seclusions. The patient is compliant with medications. The patient had some agitation, was not redirectable and required IM medication, but this appeared to be related to more chronic agitation. There was no indication the patient was going to have additional benefit. Treatment could have been addressed at a lower level of care.