Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Suicidal ideation and mood instability
Issue under review: Continued inpatient admission 
The insurer denied the continued inpatient admission.
The denial is overturned.

The patient is a male with a history of mental illness who received inpatient psychiatric treatment.

The patient has a history of mental illness including diagnosis with depression.  There have been multiple prior inpatient psychiatric hospitalizations.  There is a history of non-compliance with psychiatric treatments.  There is a history of drug and alcohol abuse and inpatient substance abuse treatment.  There is a history of medical illness including a seizure disorder, a traumatic brain injury and associated surgical shunt.  There is ongoing homelessness and unemployment.  

The patient arrived at the emergency room in an ambulance and reported suicidal thoughts and depression in context of psychosocial stressors including losing his wife.  He had been non-compliant with psychiatric treatment.  He was noted to be belligerent, uncooperative, with loose associations, thought blocking, and disorganized thought process.  He also expressed homicidal ideation to "shoot up shelter in Bronx."  

The patient was medically cleared for psychiatric admission and was admitted to the inpatient unit.  He received multidisciplinary treatment from nursing, therapy, and psychiatry staff.  He received group and individual treatment.  He received a psychopharmacology assessment and was started on Seroquel, Risperidone, Latuda, Lexapro, and Wellbutrin for his psychiatric symptoms and Keppra for his seizure disorder.

The patient was noted to have a depressed mood with persistently poor insight and judgement.  Agitation ,aggressiveness, restlessness, and psychomotor retardation were noted.  A social work note noted "his mood continues to be depressed" and he "does not feel safe in the shelter."  He was noted to be avoidant at this time.  The patient reported suicidal ideation.  The patient reported suicidal ideation again and this was discussed with his physician.  It is explicitly noted that "discharging the patient prematurely could have put both himself and others at unnecessary risk of harm and therefor it is extremely evident that the entirety of this inpatient stay was completely medically necessary before a safe discharge from the hospital was possible."

The patient was noted to be safe for discharge and was discharged with a plan for outpatient psychiatric follow up.

Yes, the proposed continued inpatient admission was medically necessary.  

The patient represented an elevated risk of dangerous behaviors including aggressive behaviors, self-injury, and suicide, and there was no less-restrictive treatment environment appropriate.  Therefore, the treatment was medically necessary.  Even when the patient was not reporting active suicidality or homicidality, the patient remained symptomatic.  The patient had multiple static risk factors for potentially dangerous behaviors including brain injury, 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 with suicidality was 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