Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Schizoaffective Disorder 
Treatment:  Inpatient Mental Health Stay 

The insurer denied the inpatient mental health stay. The health plan's determination is overturned. 

This is a patient with schizoaffective disorder, bipolar type and co-occurring substance use with the use of cocaine and cannabis. She was admitted to acute inpatient level services with severe symptoms of psychotic and mood disorder with acute symptoms of psychosis and agitation. The patient's admission had been precipitated by aggressive and threatening behavior at her homeless shelter in the context of severe substance use disorder and non-compliance with her mental health treatment. She had stopped her medication, risperidone at an unknown dose. The patient had required police intervention because she was spitting at the other residents at the shelter and was threatening harm. She was combative and assaultive when the police arrived and required intramuscular (IM) medication upon arrival at the emergency department. 
The patient has a history of multiple prior admissions for psychiatric treatment for schizoaffective disorder. The patient had been non-adherent with medications and non-compliant with outpatient treatment in the context of active substance abuse with cocaine and cannabis. She had a history of violent and aggressive behavior when manic. There were no acute general medical issues in this case; and laboratory assessments were normal or unremarkable with a positive drug screen consistent with history. 
The patient is homeless living in shelters, unemployed, and has limited or no social supports. She had been arrested at the time of her encounter with police with a court date pending. 

On the Mental Status Examination on admission, the patient appeared unkempt and disheveled with guarded stance and uncooperative behavior, and psychotic symptoms that included paranoid thinking with irritable and labile affect. She displayed an irritable mood with anxiety and slowed mentation. She had decreased concentration, sleep, and volition. Her speech was coherent but disorganized. Insight and judgment were limited and impaired with poor control of impulses. 

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 medications with an initial dose of risperidone at one milligram twice daily, titrated as clinically appropriate. The patient was initially paranoid and socially inappropriate with labile affect and continued agitation, she remained dysphoric and irritable with hostility, anger, tension and excitability requiring medication adjustments with the addition of Cogentin and Neurontin, as well as use of Invega Sustenna at an initial dose of 234 mg. She had persistent motor agitation and labile affect addressed with safety monitoring and as needed (prn) medications while her oral risperidone was titrated to three mg twice daily together with Cogentin. The patient made unsteady progress with participation in select groups focusing on illness education, illness recovery, and reality testing. She had bouts of erratic behavior with pacing and motor agitation. She was medication adherent and compliant with her treatment plan. Her agitation eventually resolved and her mood improved with better sleep and improving insight. She received a second dose of Invega Sustenna at 156 mg with plans for outpatient aftercare to address the co-occurring schizoaffective disorder and substance use disorders with plans for another injection of the Invega Sustenna after 30 days and continued use of oral risperidone, Neurontin and Cogentin and with referral for housing and other services to support abstinence from substance of abuse. 

A discharge plan was completed including plans for after care and a return to the community with housing/shelter. At the time of discharge, the patient was better focused, calmer, and displaying better judgment with improved mood and brighter affect. Discharge occurred with clinically appropriate aftercare in collaboration with community providers to include mental health services with a safety plan, as well as recommendations to address the co-occurring substance use disorders. 

The health plan documents including case notes, and appeal documents were reviewed, as well as correspondence from the health plan and the treatment facility. Case records were reviewed with summary and progress notes and other documents. This case is a New York mandated review. 

At issue is the medical necessity of continued inpatient mental health admission and stay.
The requested health service/treatment of Continued inpatient mental health admission and stay is medically necessary for this patient. 

The patient's symptoms of psychosis and mood disorder together with continued risk of impulsive and aggressive behavior prompted the necessity for the admission and the continued acute inpatient level structure and monitoring provided through discharge. The case is complicated by active substance use disorders; and non-compliance with treatment and medication adherence problems in the context of severe psychosocial stressors with homelessness and limited social supports. The residual symptoms of mood disorder and psychosis; risk for aggressive behavior, co-occurring substance use disorders, and treatment issues related to arranging a safe and appropriate discharge plan together with a history of medication non-adherence warranted the continued services at an acute inpatient level of care. Medically necessary treatment included safety monitoring and maintaining abstinence from substances of abuse while titrating medications and initiating a long-acting injectable antipsychotic medication that was critical to the patient's treatment in the context of past non-compliance with medication treatment with oral medications. The inpatient stay thru discharge was therefore clinically appropriate and medical necessary including the inpatient level structure, intensity of services with evidence-based psychosocial interventions, and 24-hour monitoring through the day of discharge when the patient had reached a level of stability that she could return to the community with clinically appropriate follow-up and aftercare. This answer is consistent with the scientific literature, American Society of Addiction Medicine (ASAM) Criteria and published practice guideline, referenced below, as well as New York State instruction for medical necessity reviews and the application of NY State Office of Alcoholism and Substance Abuse Services (OASAS) Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) 3.0 Guidelines.