Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Bipolar disorder.
Treatment:  Continued inpatient mental health treatment.
 
The insurer denied the continued inpatient mental health treatment.  The denial is overturned.

The patient is an adult male admitted for acute inpatient evaluation and treatment of bipolar disorder with most recent episode of major depressive disorder, severe and recurrent with psychotic features.  The patient presented with a history of worsening symptoms of depression with agitation and aggressive behavior in the context of psychosis and deteriorating.  He reported poor appetite with weight loss to 98 pounds down from 140 pounds at five feet and eight inches of height; in the emergency department he expressed worry that he was going to be harmed and had sleep disturbance.  He had stopped his medications and was not following up with his outpatient psychiatrist.

The patient has a history of bipolar disorder with most recent episodes depressed with psychotic features and past history of mania or hypomania.  He had one prior psychiatric hospitalization and outpatient aftercare with medication management.  The patient has a history of an eating disorder with anorexia.  He has a remote history of alcohol and tobacco use.

His mental status examination included depressed mood and flat affect with motor agitation.  He had no evidence for internal stimuli, but had paranoid thought content with persecutory delusions, as well as the mood disturbance with morbid thoughts and ruminations and severe anxiety and agitation.  He was guarded, uncooperative and disheveled.  His insight was limited, and judgment impaired with inability to care for self.  He denied suicidal ideation or aggressive impulses and was notably withdrawn though agitated, due to his psychotic thought content.  He had decreased appetite, concentration, energy, sleep and volition with the weight loss.

Yes, the proposed treatment, continued inpatient mental health treatment, was medically necessary for this patient.

The patient required the admission and the continued acute inpatient level care and the structure and monitoring of an acute inpatient level setting in order to remain safe and to receive treatment for his psychiatric disturbances, bipolar mood disorder and comorbid eating disorder, while conducting an evaluation and while observing his functioning with the resumption/adjustment of clinically appropriate medications.  The clinical course was complicated by medication non-adherence, a lack of insight, and functional impairment being addressed during the time interval under review.  Additionally, the treatment team was planning for a safe and clinically appropriate disposition with aftercare arrangements in concert with the patient's mother, with whom he lived.

The medical necessity for the continued inpatient level structure and monitoring is reasonable and in the patient's best interest, in view of the patient's severe symptoms of mood disorder, risk for relapse, and co-morbid eating disorder.  And, in view of these clinical features and the complicated presentation with psychosis and deterioration in functioning, the patient's continued active treatment with safety monitoring was warranted in the context of the patient's deteriorated functioning and stressors involving primary support and general medical domains.  Additionally, the inpatient stay was medically necessary in order to monitor the response to medications, to insure that the patient will have a sustained response to treatment, and to continue to address the acute risk of relapse or non-compliance or rehospitalization in the context of severe symptoms of bipolar mood disorder in a patient with impaired judgment and a lack of insight.  The necessity for continued inpatient level services reflects sound medical judgment in keeping with prevailing standards of professional practice and with the published practice guidelines and criteria, referenced below, as well as New York State instruction for medical necessity reviews.