Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Suicidal and Homicidal Ideation.
Treatment: Inpatient hospital admission. 
The insurer denied the inpatient hospital admission.
The denial is upheld.

The patient is a male. He was admitted to the acute inpatient pediatric unit, awaiting a bed in an acute inpatient psychiatric facility. He was diagnosed with behavioral and emotional disorders but onset usually occurring in childhood and adolescence. Other diagnoses indicated include suicidal ideations, sleep disorder, attention deficit hyperactivity disorder and other viral infections. The patient was reported to have been admitted for worsening symptoms of agitation, aggression, irritability, impulsivity, and suicidal and homicidal ideations in the context of significant psychosocial stressors including conflicts with family. He was reported to have been referred by the school psychologist after the patient was noted to have drawn a picture of himself with a gun shooting himself. He was reported to have indicated that he wanted to kill himself and his mother. The patient was noted to have been assessed by a mobile crisis team prior to being brought to the emergency room.

The patient was provided with individual, group, and family therapy while on the inpatient unit. He was not prescribed any psychotropic medications during his stay on the inpatient unit. The patient was noted to have been administered as needed medications for agitation and aggression. He was not reported to have any significant adverse effects from his medications.

There was no indication that the patient was at imminent risk of harm to himself or others at the time of his admission. He was noted to have expressed thoughts of killing himself and his mother with a gun. However, there was no indication of the patient had access to means or intent. The patient was not reported to have any active suicidal or homicidal ideations with plans or intent. He was not reported to have any symptoms suggestive of psychosis including command hallucinations, persecutory delusions, or extreme paranoia. He was not reported to have any symptoms of mania or hypomania. He was noted to have intermittent episodes of agitation and aggression while on the inpatient unit which were noted to be his baseline.

The patient was not reported to have any significant ongoing medical problems that required hospital-based interventions or monitoring. He was not reported to have significant functional impairments including age-appropriate activities of daily living and self-care that represent a change from his baseline. The patient was not reported to have any significant adverse effects from his medication. He was noted to be participating in treatment and largely compliant with unit routines. There was no significant deterioration or emergence of new psychiatric symptoms during the patient's stay on the inpatient unit. The patient was discharged to continue outpatient treatment.

No, the requested acute inpatient hospitalization was not medically necessary.

Based on current peer-reviewed medical literature, the requested service (acute inpatient hospital stay) was not found to be medically necessary. The clinical information provided does not indicate that the service requested was the least restrictive setting that was medically necessary or was likely to be successful in treating the patient's symptoms (1-17).

The patient is a male who was admitted to the acute inpatient pediatric unit, awaiting a bed in an acute inpatient psychiatric facility. He was diagnosed with behavioral and emotional disorders but onset usually occurring in childhood and adolescence. Other diagnoses indicated include suicidal ideations, sleep disorder, attention deficit hyperactivity disorder and other viral infections. The patient was reported to have been admitted for worsening symptoms of agitation, aggression, irritability, impulsivity, and suicidal and homicidal ideations in the context of significant psychosocial stressors including conflicts with family. He was reported to have been referred by the school psychologist after the patient was noted to have drawn a picture of himself with a gun shooting himself. He was reported to have indicated that he wanted to kill himself and his mother.

There was no indication of the patient was at imminent risk of harm to himself or others at the time of his admission. He was noted to have expressed thoughts of killing himself and his mother with a gun. However, there was no indication of the patient had access to means or intent to carry out his plan (10-17). He was not reported to have any symptoms suggestive of psychosis including command hallucinations, persecutory delusions, or extreme paranoia. He was not reported to have any symptoms of mania or hypomania. He was noted to have intermittent episodes of agitation and aggression while on the inpatient unit which were noted to be his baseline (1-9).

The patient was not reported to have any significant ongoing medical problems that required hospital-based interventions or monitoring. He was not reported to have significant functional impairments including age-appropriate activities of daily living and self-care that represent a change from his baseline. The patient was not reported to have any significant adverse effects from his medication. He was noted to be participating in treatment and largely compliant with unit routines. There was no significant deterioration or emergence of new psychiatric symptoms during the patient's stay on the inpatient unit. The patient may have been treated safely and effectively in a less restrictive setting in lower level of care. He may have been treated at an observation level of care at the time of his presentation. Therefore, based on current peer-reviewed medical literature, the requested service (acute inpatient hospital stay) was not found to be medically necessary.

Yes, the health plan did act reasonably, with sound medical judgment, and in the best interest of the patient.

Clinical information were reviewed does not indicate that the patient was at imminent risk of harm to himself or others at the time of his admission. He was noted to have expressed suicidal and homicidal ideations. However, there was no indication that the patient had the means to carry out his plans or intent to harm himself or others. The patient may been treated safely and effectively with observation followed by behavioral health treatment in a less restrictive setting. Therefore, the health plan was noted to have acted reasonably, with sound medical judgment, and in the best interest of the patient.