Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Schizophrenia

Treatment: Inpatient Mental Health Treatment

The insurer denied coverage for inpatient mental health treatment.

The denial is overturned.

This female reportedly was admitted to this inpatient mental health treatment in this hospital due to a suicide attempt by jumping out a second floor window and landing face first, causing multiple lacerations to the chest and face and damaging her teeth. She reportedly had command auditory hallucinations suicidal in nature, telling her to jump out the window. She reportedly had paranoid delusional thinking, bizarre thinking and behavior, internal preoccupation, anxious and depressed mood, poor activities of daily living (ADLs), and poor social skills. She reportedly had a diagnosis of Schizoaffective Disorder-Bipolar Type. She reportedly was taking Clozapine and Haldol Decanoate. She was later discharged.

The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Schizophrenia reports that patients with hallucinations, delusional thinking, disorganized thinking or behavior, suicidal or homicidal plan or intent, agitation, or aggressive behavior are candidates for inpatient treatment. Also, the Milliman Care Guidelines (MCG) Behavioral Health Inpatient Level of Care Adult criteria reports that a patient needs to present as an imminent danger to self or others, with severe psychiatric or behavioral symptoms, have a severe dysfunction in activities of daily living, including inability to care for self and/or unwillingness to participate in treatment voluntarily, to justify an inpatient level of care. This patient met criteria for inpatient behavioral health level of care, as in this case this patient had reports of severe psychiatric symptoms including psychotic symptoms that interfered with her functioning and ability to care for herself, so she still required further hospital treatment until discharge. 

In this case, this patient had a very serious suicide attempt by jumping out a second floor window and landing face first causing multiple lacerations to the chest and face and damaging her teeth. Notes reported that she was talking to herself and disheveled, had paranoid delusional thinking, depressed mood and flat affect, and still had tongue stiffness. Other notes reported that she still had command auditory hallucinations telling her to jump out the window and hurt herself. Additional notes reported that she was having auditory hallucinations, though she was talking to herself less. Notes reported that she was depressed in mood, apathetic, had impaired reality testing, and dysphoric mood. Notes reported that she heard voices talking to her at night, paranoid thinking, feeling unkempt, disheveled, overwhelmed, depressed in mood, with impaired ADLs and social skills and was too at risk if she were to leave the hospital. Notes reported that she heard voices and had paranoid thinking (though less often), was depressed in mood, unkempt, disheveled and was taking Clozapine and Haldol Decanoate. She reportedly improved in symptoms and was discharged. She was still considered in need of continued inpatient psychiatric hospital treatment due to her being at risk for suicide due to a serious suicide attempt on admission, resulting in injuries and continued psychotic symptoms, including auditory hallucinations and paranoid delusional thinking. 

Continued inpatient mental health treatment in this hospital was medically necessary, as the patient was discharged and the medical records for review did provide enough specific evidence to support that she required 24 hour hospital treatment.

The health care plan did not act reasonably, with sound medical judgment, or in the best interests of the patient.

The insurer's denial of coverage for the continued inpatient mental health is reversed. Medical necessity is substantiated.