Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Depressed mood; suicidal ideation; suicide attempts
 
Treatment: Inpatient mental health treatment

The insurer denied coverage for inpatient mental health treatment. The denial is upheld. 

This patient is a female was admitted to this inpatient mental health treatment in this hospital due to worsened depressive symptoms including depressed mood and suicidal ideation. She had bought a bottle of pills and had past suicide attempts by overdose. She was crying, had decreased concentration, increased sleep, decreased eating, and she was obsessing, feeling overwhelmed, and had medication noncompliance. She had four past suicide attempts including an overdose resulting in a hospitalization. She had three past psychiatric hospitalizations. She had a diagnosis of Major Depressive Disorder. She took Prozac and Lithium and improved. She was discharged.

The insurer denied coverage for continued inpatient mental health treatment in this hospital for a specified date range. This reviewer agrees with the decision to deny coverage for inpatient mental health treatment for the date range specified. The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Suicidal Behaviors reports that patients with past suicide attempts are at high risk for suicide and that past suicide attempts are the single most reliable predictor of suicide. It also states that patients with major depressive episodes and victimization of abuse are at increased risk for suicide. This patient had four past reported suicide attempts including a recent one and presented with current suicidal ideation and worsened depression. The patient had bought a bottle of pills.  She had a diagnosis of Major Depressive Disorder with victimization issues; therefore, she was considered a danger to self and in need of 24-hour hospitalization on admission.

Notes reported depressed mood and blunted affect. With her history of past suicide attempts and suicidal ideation on admission, she was still considered a danger to self and in need of 24-hour hospital treatment. Notes on the following day reported improved mood with bright affect and no reports of suicidal ideation; however, she required at least two days of observation without reported suicidal thoughts or major depressive episodes due to her past suicide attempts and recent suicidal thoughts on admission. Notes a couple of days before the discharge date reported that she denied thoughts of harm to self, homicidal ideation or hallucinations, and was in no acute distress. Also on the day before discharge she had a bright affect, fine mood, and denied suicidal or homicidal thoughts or hallucinations.

This patient was considered at risk for suicide upon admission and for a few days after admission while still having depressed mood. She was in need of being observed for significant depressive symptoms or suicidal thoughts due to her history of suicide attempts and suicidal thoughts and depression on admission. However, by a specified date there were no reports of further suicidal ideation, plan, or intent, no reports of self-injurious behavior, severe depressive symptoms, withdrawal symptoms, severe agitation, aggression, psychotic symptoms, or acute medical instability. As of that date there were no reports of specific identifiable treatment goals or objectives that could only be achieved in this 24-hour hospital treatment or that could not be achieved in a less restrictive setting. 

The insurer acted reasonably, with sound medical judgment, and in the best interests of the patient from the specified date range. 

Based on the above, the medical necessity for the continued inpatient services is not substantiated. The insurer's denial is upheld.