Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Major Depressive Disorder; Post-Traumatic Stress Disorder.
Treatment: Inpatient mental health treatment.
The insurer denied inpatient mental health treatment.
The denial was modified.   

This male patient with a history of major depressive disorder (MDD) and post-traumatic stress disorder (PTSD) was admitted for inpatient mental health treatment due to his worsened depressive symptoms including suicidal ideation, depressed mood, feelings of hopelessness and helplessness, decreased interest and energy, decreased appetite, sleeping problems, limited impulse control, agitation, concentration problems, poor activities of daily living (ADLs), and somatic complaints due to multiple medical issues. The patient's past history was significant for suicide attempt one year prior to this admission by overdose. The patient took Zoloft, risperidone, and trazodone. He was stabilized and was then discharged.

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 as past suicide attempts are the single most reliable predictor of suicide. Patients may require more time in the hospital to better assess suicide because they sometimes do not tell the truth regarding their suicidal thoughts in order to leave the hospital and that observation in the hospital is appropriate to better ensure their safety.

In this case, this patient was considered a high risk patient and benefitted from remaining in the hospital and being observed and assessed for safety until 11 days after admission. Notes on day 10 showed the patient continued to receive acute psychiatric hospital treatment for depression and his suicidal thoughts, was not at his baseline yet, and needed more time in this hospital setting. Notes on day 11 reported that the patient's mood was down and he had multiple somatic symptoms, was not yet at his baseline functioning, and his affect and insight required significant improvement. The medical records until day 11 provided enough evidence to support the need for continued hospital treatment.  

However, notes as of day 12 did not report severe depressive symptoms, suicidal thoughts, and did not support that the patient only required 24-hour hospital treatment. The patient denied suicidal/homicidal ideation, had good behavioral control, and stated that his depression was improving, and he had a better overall frame of mind, had resolution of suicidal ideation, no delusions, and improved impulse control. He was calm, cooperative, adequately dressed and fairly groomed, took medications, had no hallucinations, self-harm, suicidal or homicidal thoughts. There were no reports of suicidal or homicidal ideation, intent, or plan, inability to adequately care for basic needs, manic episodes, psychotic symptoms, self-injurious, aggressive, threatening, or agitated behavior, specific evidence that he was an imminent danger to self or others or unable to adequately care for his basic needs.  Also, as of then there were no reports of specific identifiable or quantifiable treatment goals or objectives that could only be achieved in a 24-hour acute psychiatric hospital setting or that could not be achieved in a less restrictive setting.  

Based on the review above, the continued inpatient mental health treatment in this hospital for 11 days was medically necessary for this patient. However, continued inpatient mental health treatment beyond 11 days was not medically necessary for this patient. 

It appears that the health plan acted reasonably with good clinical judgment and in the best interests of the patient for the last 3 dates of service but did not for dates of service on days 10 and 11.

The carrier's denial of coverage for the 4 Units of continued Inpatient Mental Health Treatment should be modified. Approve day 10 and 11. Deny days 12 to 15.