Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Mental Health. 
Treatment: Mental Health Inpatient. 
The insurer denied the inpatient stay. 
The denial was overturned in whole. 

The patient is a male with schizoaffective disorder, depressed type and co-occurring substance use disorder (tobacco and cannabis). He was admitted to acute inpatient level services with severe symptoms of depression, intermittent suicidal ideation, self-harming behavior (cutting and burning self), psychosis with persecutory delusions, and motor retardation. The patient's admission had been precipitated by worsening symptoms of depression with nonadherence with his medication and increasing use of cannabis/marijuana. The patient endorsed symptoms of depression with suicidal ideation; he was guarded at the time of presentation in the context of drug use with cannabis which worsened his paranoia.
The patient had a history of multiple prior admissions for psychiatric treatment for schizoaffective disorder and/or major depressive disorder, and had been in outpatient treatment for substance abuse and mental disorders that included a mood disorder and thought disorder, together with the cannabis and tobacco class substance use disorders.
There were no acute general medical issues in this case; and laboratory and electrocardiogram (EKG) were normal or unremarkable with a positive drug screen for tetrahydrocannabinol (THC) consistent with history. The patient has morbid obesity with a body mass index (BMI) of 39-40. A computed tomography (CT) scan of the head was normal.
The patient is single with a high school education, unemployed, and lives with family. There was no mention of trauma history or legal issues in this case.
Mental Status Examination on admission: The patient was motor retarded, guarded with poor eye contact, and psychotic with dysphoric mood and flat affect. He displayed depressed mood with slowed mentation with thought blocking. He had hopelessness, helplessness, and reported intermittent suicidal ideation.
The patient was admitted to acute inpatient level care after medical screening in the emergency department. The patient's treatment plan included safety-monitoring, access to group and milieu therapies, and resumption of medication to address mood disturbance and the thought disorder. However, he was increasingly cooperative with staff and became medication adherent with use of Depakote, titrated as clinically appropriate. The patient tended to isolate with minimal participation in the therapeutic activities. His depression and thought disorder persisted.

A discharge plan was completed including plans for after care and return to the community. At the time of discharge, the patient was better focused, calmer, and displaying better judgment with improved mood and brighter affect. The subject under review is the medical necessity for the inpatient mental health treatment.

The inpatient admission for the dates of service (DOS) under review could not have been safely or effectively provided at a lower level of care. 
The patient's symptoms of psychosis and mood disorder together with continued risk of self-harm and the inherent suicidal risk prompted the necessity for continued acute inpatient level structure and monitoring through discharge. 
The inpatient stay was therefore clinically appropriate and medical necessary through the day of discharge. This answer is consistent with the scientific literature and published practice guidelines, referenced below, as well as the NY State Office of Alcoholism and Substance Abuse Services (OASAS) Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) 3.0 Guidelines pertaining to substance use disorders diagnosed in this case.