Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Suicidal ideation
Treatment: Continued Inpatient Admission
The insurer denied the Continued Inpatient Admission. 
The denial is upheld. 

The patient is an adult male who was admitted to acute inpatient mental health treatment  for worsening symptoms of depression with suicidal ideation. The patient presented with self-referral with an exacerbation of his chronic psychotic and mood disorder best characterized as schizoaffective disorder, depressed type. The patient has co-occurring substance use disorders with opioid and sedative-hypnotic-anxiolytic class substances as his drugs of choice (buprenorphine and Xanax). There is also a past history of post-traumatic disorder (PTSD), anxiety disorder and attention deficit hyperactivity disorder (ADHD). He was participating in a Suboxone program with eight to 16 milligrams (mg) of Suboxone per day, but had been non-compliant with the program. He was also receiving outpatient mental health treatment with recent changes with his psychotropic regimen, which was thought to contribute to the patient's deterioration, as well as misuse of the Suboxone.

The patient was medically screened in the emergency department and admitted to inpatient psychiatry with a comprehensive evaluation. There were no acute general medical issues in this case though he reported withdrawal symptoms that included chills and anxiety and feeling unwell.

Mental status examination revealed an agitated and anxious male who was cooperative with the examination. He did not have evidence of a formal thought disorder and speech was clear. He demonstrated depressed mood and anxious affect that was labile with motor agitation. He reported suicidal ideation. He exhibited limited insight and fair judgment and control of impulses. 

He is unemployed with assistance for his chronic and persistent mental disorder. There was no mention of legal issues, but the patient did have unspecified trauma history with the past diagnosis of post-traumatic stress disorder (PTSD).

The patient's treatment plan included monitoring, medication targeting symptoms of psychosis and mood disturbance, and the opportunity to participate in group, educational and milieu therapies. The patient initially had a difficult clinical course with regard to his depression and opioid withdrawal requiring as needed (PRN) medications including resumption of Suboxone. He received safety monitoring. His medication regimen was adjusted to include Wellbutrin, Seroquel, Depakote, gabapentin, and hydroxyzine together with vitamin supplements and nicotine replacement therapy for tobacco dependence, as well as the Suboxone gradually reduced to eight milligrams daily.

The patient was withdrawn but was participating in therapy with attendance at select groups; he was increasingly social and less withdrawn. The psychotropic medication was adjusted and monitored daily with tolerability; discharge planning had occurred as he continued treatment.  He reported feeling much better and denied suicidal ideation or aggressive impulses. 

The patient was generally cooperative and medication adherent, and had no morbid thought content though he remained mildly depressed. His affect was more appropriate, and his insight and judgment were fair. He was sleeping and eating okay with no evidence of drug withdrawal symptoms. He made additional progress through discharge, and remained stable, and he was cooperative with this treatment plan. The patient was discharged with return to the community, and recommendations for continued treatment with medication and outpatient follow up for mental health and substance use disorder services including continued use of medications, as noted.

No, the proposed treatment, continued inpatient admission was not medically necessary for this patient.

The continued inpatient level hospital care was not medically necessary for this patient. The patient no longer required the structure of an acute inpatient level of care in order to remain safe or to administer continued treatment for the psychiatric disturbance and co-occurring substance use disorders including support of daily activities and safety monitoring together with medication management and other therapeutic interventions. It was not medically necessary for this patient to receive continued acute inpatient level services in view of his improved mood and affect, resolution of overtly suicidal risk, and relative lack of impulsive behaviors, as well as improved functioning and medication adherence. There were no general medical issues or symptoms of the co-occurring substance use disorders complicating this case that would have required continued acute inpatient level services; the patient's substance use disorder did not require continued acute inpatient level treatment or 24-hour monitoring and he had access to substance abuse services in the community. Additionally, the inpatient stay during the time interval under review was not medically necessary in order to monitor the patient for at-risk behaviors, or to address the acute risk of relapse or address the issue in this case with medication non-adherence. The patient had access to continued mental health and substance abuse treatment in the community that could effectively meet the patient's continued mental health needs. Thus, treatment could have continued in a less restrictive setting and medical necessity is not met in this case for the time interval under review. This answer is consistent with the practice guidelines and scientific literature referenced below as well as New York State instruction for medical necessity reviews, and the application of NY (New York) State Office of Alcoholism and Substance Abuse Services (OASAS) Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) 3.0 Guidelines/Criteria.

The patient's presentation and clinical features included an exacerbation of the patient's psychotic and mood disorder in the context of severe symptoms of depression, and deterioration in functioning with suicidal risk. The patient had recent medication changes and medication non-adherence and substance abuse with opioids and benzodiazepine including misuse of his Suboxone. The patient responded to treatment, he had no remaining safety issues or persistent symptoms of depression that placed him at imminent risk for harm to self or others. There was no evidence of other symptoms or behaviors that would have required continued acute inpatient level of care, as noted above. The patient could have been managed at a lower level of care during the time frame under review. Thus, the health plan's determination is reasonable and reflects sound medical judgment. This answer is consistent with the practice guideline and scientific literature referenced below as well as New York State instruction for medical necessity reviews, and other references pertinent to the patient's co-occurring substance use disorders including the application of NY (New York) State Office of Alcoholism and Substance Abuse Services (OASAS) Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) Criteria-referenced below.