Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Major depressive disorder, single episode, unspecified (F32.9)
Treatment: Continued Stay Inpatient Behavioral Health Level of Care
The insurer denied: Continued Stay Inpatient Behavioral Health Level of Care
The denial is upheld

The patient is a teenage male who was initially admitted to the acute inpatient level of care on awaiting an acute inpatient psychiatric bed. The patient was noted to have been eventually admitted to an acute inpatient psychiatric unit. He was reported to have been diagnosed with major depressive disorder, single episode, unspecified (F32.9). He was reported to have been admitted for worsening symptoms of depression, self-harm behaviors and suicidal ideations with a plan to jump off a high-rise building in the context of significant psychosocial stressors. The patient was reported to have expressed suicidal ideations to his school counselor following which he was brought to the emergency room. This review pertains to the medical necessity of continued acute inpatient psychiatric hospitalization which was previously denied as not medically necessary. 

The proposed treatment (continued acute inpatient psychiatric hospitalization) was not medically necessary.

Based on current peer reviewed, evidence based medical literature, the requested service (acute inpatient psychiatric hospitalization 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 was likely to be successful in treating the patient's symptoms (1-8). The patient is a teenage male who was initially admitted to the acute inpatient level of care awaiting an acute inpatient psychiatric bed. The patient was noted to have been subsequently admitted to an acute inpatient psychiatric unit. He was reported to have been diagnosed with major depressive disorder, single episode, unspecified (F32.9). He was reported to have been admitted for worsening symptoms of depression, self-harm behaviors and suicidal ideations with a plan to jump off a high-rise building in the context of significant psychosocial stressors. The patient was reported to have expressed suicidal ideations to his school counselor following which he was brought to the emergency room. The patient was noted to be largely stable and at baseline with no significant acute behavioral difficulties that required inpatient psychiatric hospitalization. He was not reported to have any active suicidal or homicidal ideations, plans or stated intent. He was not reported to have exhibited any significant aggression or agitation while on the inpatient unit. He was not reported to have any symptoms suggestive of command hallucinations, persecutory delusions or extreme paranoia. The patient was not reported to have any significant history of substance abuse. The patient was not reported to have any significant adverse effects from prescribed psychotropic medications. The patient was not reported to have any significant ongoing medical conditions that required hospital-based interventions or monitoring. The patient was not reported to have any significant functional impairments including activities of daily living or self-care. He was not reported to have any significant deterioration or emergence of new symptoms for the rest of his stay on the inpatient unit. The patient may have been treated safely in a less restrictive setting and lower level of care. The patient did not meet medical necessity criteria for acute inpatient mental health treatment. There was no indication that the patient continued to exhibit measurable improvements in behavior and symptoms with ongoing treatment at the acute inpatient psychiatric level of care. There was no indication that any significant changes in treatment plan were required. Therefore, continuing inpatient psychiatric hospitalization was not found to be medically necessary.