Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Depression, trouble with thinking.
Treatment:  Inpatient Psychiatric Hospitalization.
 
The insurer denied the Inpatient Psychiatric Hospitalization.  The denial is overturned. 

Yes, the Inpatient Psychiatric Hospitalization is medically necessary. 

The patient is a woman with a history of mental illness, who was hospitalized for psychiatric illness.  She has a history of diagnosis with schizophrenia, multiple prior inpatient psychiatric hospitalizations.  She has a medical history of hyperthyroidism and chronic tobacco abuse.  She is unemployed and medication non-adherent.  The patient reported worsening auditory hallucinations of people trying to have sex with her and wanting to kill her.  She had poor appetite, anhedonia, aggravation, depression and was brought into the hospital by an ambulance for evaluation.  She was medically cleared for psychiatric hospitalization and was admitted.

The patient was treated by a multidisciplinary team including psychiatry, nursing, and therapy staff.  She received individual and group treatment.  She received a psychopharmacology evaluation and was treated with Olanzapine, as well as other prn (as needed) medications.  She was noted to be internally preoccupied with delusions and hearing voices.  Her Olanzapine dose was increased.  She was noted to be internally preoccupied, isolative and withdrawn with anxiety and poor hygiene, as well as covering her head with a scarf.

The patient was noted to  be stable for discharge and was discharged with a plan for ongoing psychiatric treatment.

The patient represented an acutely elevated risk of dangerous behaviors and there was no less-restrictive treatment environment appropriate.  The acute risk factors of psychosis with the chronic risk factors of potentially dangerous behaviors suggest that the patient would have been at an acute risk of aggressive or self-injurious behaviors (including but not limited to suicide) were she to have been discharged from the inpatient hospital setting.  The patient was discharged from the inpatient psychiatric hospital setting as soon as a less-restrictive treatment setting was appropriate.  

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.  While the patient was not endorsing active suicidality or homicidality, the patient remained psychotic and disorganized with severe symptoms.  The patient had multiple static risk factors for potentially dangerous behaviors including medication non-adherence, prior hospitalizations, and diagnosis with a severe mental illness.  Therefore, the patient represented a chronic risk of potentially dangerous behaviors.  The fact that patient remained psychotic with recent medication changes were 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.