Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Suicidal ideation
Issue under review: Continued inpatient admission

Determination:
The Continued inpatient admission was medically necessary.

The patient is an adult female with a history of mental illness and substance abuse who was treated at the hospital.

The patient has been diagnosed with mental illness and has Bipolar Disorder.  She has a history of alcohol dependency.  She has a history of psychiatric hospitalizations.  There is a history of non-compliance with psychiatric treatment and suicide attempts requiring treatment in the ICU.  She has no community support and is homeless.  There is a medical history of hypertension, hyperlipidemia, GERD (gastroesophageal reflux disease), HCV (Hepatitis C virus), and chronic back pain.

The patient was initially admitted to the psychiatric unit for depression, suicidal ideation, and alcohol withdrawal.  She was found to have stroke-like symptoms and was transferred to the medical ward, where she was treated for a UTI and returned to the psychiatric ward.  More medical tests were required and the patient again returned to the medical ICU for fever and delirium.  She returned to the psychiatric unit 13 days later.  

The patient was treated by a multidisciplinary team including psychiatry, nursing, and therapy staff.  She was treated with individual and group therapy.  She received substance abuse treatment.  She received a psychopharmacology evaluation and was treated with Tegretol 200mg BID, Seroquel 100mg daily, Clonazepam 1mg PO TID, and Donepezil 10mg daily.  Tegretol was increased to a total of 1000mg in divided doses.  Seroquel was increased to 400mg PO QHS.  Gabapentin was started and increased to 100mg TID.  Prozac 20mg was added.  Clonazepam was tapered off and Topamax was started and tapered to 150mg PO BID.  Melatonin was added for sleep.  Remeron was added at 15mg PO QHS.  An assisted outpatient treatment order was obtained through Suffolk County.  Community Residence Housing was secured as was outpatient psychiatric treatment and a plan was in place for this prior to discharge.

It is clearly documented that discharging the patient without appropriate community resources and supports "would likely result in a decompensation of [the patient's] mental health, possibly leading again to a life-threatening crisis."

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 with multiple static risk factors for potentially dangerous behaviors, including substance abuse, suicide attempts, and diagnosis with a severe mental illness.  Therefore the patient represented a chronic risk of potentially dangerous behaviors.  The fact that patient remained without any outpatient treatment resources and without demonstrated treatment adherence 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.

The patient represented an acutely elevated risk of dangerous behaviors, and there was no less-restrictive treatment environment appropriate.  The acute risk factors of recent delirium and no significant treatment resources in the outpatient setting 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.