Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Major Depression
Treatment: Full Hospital Admission
The insurer denied coverage for full hospital admission
The denial is overturned

This adult male was transferred from the behavioral health unit to the telemetry due to multiple falls, dizziness, lightheadedness, laceration from a fall, and monitoring for a possible arrhythmia due to syncope. The patient's blood pressure was 155/88 and 146/90. The patient had been in the behavioral health unit due to worsened depressive symptoms including dysphoric mood, feelings of hopelessness and helplessness, suicidal thoughts, a suicide attempt, low motivation, withdrawn, and feeling very depressed. The patient was on constant observation due to hopelessness and suicidal thoughts. He was on the medical unit and when medically cleared, he was transferred back to the behavioral health unit for further mental health treatment for depression including hopelessness and suicidal thoughts.
  
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 and also that hopelessness increases the risk of suicide. This patient was considered at risk for further suicide if not in a 24-hour hospital setting as he reportedly had a suicide attempt, worsened depression, and hopelessness. It was reported that he had depressed mood, suicidal thoughts, hopelessness, and helplessness. It was reported that he was very depressed mood, had suicidal ideation, was withdrawn and dysphoric, and had hopelessness and helplessness. With his reported suicide attempt and continued feelings of hopelessness and feeling very depressed with suicidal thoughts, he was still considered at risk for suicide and in need of 24-hour hospital treatment even if on the medical unit with close observation. It was reported that he had medical issues and needed to be observed on a telemetry unit due to multiple falls, dizziness, lightheadedness, laceration from a fall, and monitoring for a possible arrhythmia due to syncope. This reportedly could not be done on a psychiatric unit, so he required the hospital treatment on the medical telemetry unit until medically cleared for transfer back to the behavioral health unit. This patient was considered to be a danger to self due to a suicide attempt with depression still and hopelessness with suicidal thoughts, so he required the hospital time. He was on 1:1 observation. Also, the Milliman Care Guideline (MCG) Behavioral Health-Adult-Inpatient Level of Care guidelines reports that one needs one of the following: presenting as an imminent danger to self, imminent danger to others, severe psychiatric or behavioral symptoms, a severely dysfunctional living including inability to care for self, unwilling to participate voluntarily, or if a less restrictive level of care is not feasible meet criteria for inpatient behavioral health level of care. In this case, the patient was considered a danger to self due to a suicide attempt with major depressive symptoms still and was considered a risk of harm to self if discharged prematurely.

The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for the full hospital admission is overturned. Medical Necessity is substantiated.