Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Attempted suicide
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission.
The denial is overturned.
 
This adult patient reportedly was admitted to this inpatient hospital due to a suicide attempt by overdose of Tylenol and Trazodone and had worsened depressive symptoms and had hepatorenal syndrome. She reportedly was admitted to the medical floor and was COVID positive. She reportedly had a heart rate as high as 136 and had dehydration. She had a creatinine of .7 and lactate of 2.8. She was given intravenous (IV) fluids and was being monitored for hypothermia and QTC (heart wave) prolongation. She reportedly was seen by the psychiatric consultant who recommended inpatient psychiatric hospitalization when medically cleared as she was COVID positive. She reportedly had a diagnosis of Schizoaffective Disorder-depressive type. She reportedly had a suicide attempt by overdose and had depressed mood, hopelessness, sleeping problems, and had past noncompliance with treatment and medications and past minimization of symptoms. She reportedly had a past suicide attempt by Tylenol overdose with hepatorenal syndrome. She reportedly was taking Paliperidone, Fluoxetine, and Zolpidem. The psychiatric consultant reported that the patient was not cleared for discharge and required inpatient psychiatric hospital treatment when medically cleared as she had COVID. She reportedly was COVID negative and was discharged to the psychiatric unit for psychiatric hospital treatment.
  
The medical records provided enough specific evidence to support that she required this inpatient level of care. The Milliman Care Guidelines (MCG) Drug Ingestion or Overdose criteria reports that one meets criteria if one of the following are met: hemodynamic instability, dangerous arrhythmia, respiratory abnormalities, hypertension requiring inpatient treatment, specific finding indicating severe and prolonged drug toxicity, or inpatient admission is required other than observation care. Also, the American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Suicidal Behaviors reports that patients with suicide attempts are at high risk of suicide. Suicide attempts are the single most reliable predictor of suicide. 

This patient was considered an imminent danger to self-due to an overdose of Tylenol and Trazodone in a suicide attempt with hepatorenal syndrome and had worsened reported depressive symptoms including depressed mood, hopelessness, and sleeping problems. She reportedly had a past suicide attempt by Tylenol overdose and had past psychotic symptoms as well including disorganization. She reportedly had a history of noncompliance and of minimizing her symptoms. She reportedly was also at medical risk due to the suicide attempt and was being monitored for prolonged QTC as her heart rate was as high as 137 reportedly and she had dehydration and hepatorenal syndrome and had a creatinine of .7. The psychiatric consultant stated that she was not cleared for discharge and required inpatient psychiatric hospital treatment when medically cleared. She also was COVID positive and could not be transferred until no longer COVID positive. 

Also, the APA Practice Guidelines for the Treatment of Patients with Suicidal Behaviors reports that patients may require more time in the hospital to better assess suicide because they sometimes do not tell the truth regarding their suicidal thoughts in order to leave the hospital and that observation in the hospital is appropriate to better ensure their safety. 

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for inpatient hospital services is substantiated.