Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Psychotic Disorder. 
Treatment: Inpatient Mental Stay. 

The insurer denied the Inpatient Mental Health Stay. 
The determination is upheld. 

The patient was admitted to acute inpatient mental health treatment for worsening symptoms of a psychotic disorder in the context of medication non-adherence and severe psychosocial stressors. He exhibited erratic and aggressive behavior that resulted in his presentation to an emergency department with medical clearance and referral for acute inpatient care. He has a history of a chronic psychotic disorder within the schizophrenia spectrum treated with medication and outpatient mental health treatment including assertive community treatment (ACT) services. Upon initial evaluation, there were no acute general medical issues other than elevated blood pressure. The patient refused most of the physical examination and laboratory assessments and was acutely agitated requiring intramuscular (IM) Haldol, Benadryl and Ativan in the emergency department. 

Mental status examination revealed an uncooperative and disheveled male who was malodorous with poor eye contact. He was restless with delayed speech that was illogical and incoherent. He demonstrated poverty of thought that was illogical and disorganized. The patient was responding to internal stimuli and expressing homicidal intent with paranoid delusions. He exhibited limited insight and impaired judgment and poor control of impulses with the recent impulsive aggression and erratic behavior, as noted. 

The patient is homeless and unemployed. He was a poor historian and had no social supports other than the mental health providers in the community with whom he had been non-compliant, failing to follow up with treatment and living on the street. There were no legal issues or trauma history reported in this case. The patient was not diagnosed with a substance use disorder. 

The patient received monitoring, medications targeting symptoms of psychosis, and had the opportunity to participate in group, educational and milieu therapies. The patient had a difficult clinical course during the first 2 months of his inpatient stay with regard to persistent symptoms of acute psychosis and functioning. He tended to isolate and did not participate in groups. He was adherent with medications but continued to refuse laboratory assessment. He was initially started on risperidone and amlodipine. Despite ongoing treatment with safety monitoring and assistance with daily activities, the patient remained overtly psychotic with behavior requiring staff direction, safety monitoring and assistance with activities of daily living (ADLs). 

The patient became increasingly more cooperative. A court order allowed for laboratory testing that affirmed that there were no acute medical issues; he had evidence for dyslipidemia and type II diabetes mellitus and was started on metformin and Crestor. His risperidone had been cross tapered with olanzapine, titrated as clinically appropriate. The patient's symptoms of psychosis slowly diminished with residual symptoms of thought disorder, improved mood and better cooperation. He did remain irritable and continued to require monitoring and assistance with medications and daily activities with a tendency to be irritable in the evenings. He was otherwise calm with diminished anxiety, and sleep and appetite that were okay. He was sometimes easy to engage though he continued to have poverty of thought and labile affect. He denied suicidal and homicidal ideation and had no further evidence of perceptual disturbance. He had not shown aggressive behavior and denied violent intent. 

The patient's clinical course was generally stable, though the patient attended few groups and was not fully engaged with milieu activities. Applications for the State Hospital and Supervised Group Homes had been placed, as he was thought to require more structure and supervision than an Assertive Community Treatment (ACT) team could provide. 

For the remainder of his stay, the patient displayed better control of impulses, compliance with treatment (medication adherence), and better functioning overall though he was irritable and required staff support for activities of daily living. His thoughts were more linear and goal direct with improved insight and fair judgment. He was generally depicted as calm and cooperative with staff. The patient was discharged with clinically appropriate aftercare and placement in a supervised group home with continued medications for the psychotic disorder and general medical conditions. 
The case records, health plan documents, appeal documents and correspondence from the treatment facility and the health plan, as well as the health plan's level of care guidelines and rationale for the denial of certification for coverage on the basis of medical necessity, were reviewed. This case is a New York State mandated review.
The issue under review is the medical necessity of continued inpatient psychiatric services. 

The acute inpatient mental health stay and treatment is not medically necessary for this patient. The patient no longer required the structure or the 24 hour monitoring of an acute inpatient level of care in order to remain safe or to administer continued treatment for the psychiatric disturbance including support of daily activities and safety monitoring. It was not medically necessary for this patient to have acute inpatient level services in view of his improved functioning and better control of the psychotic symptoms, and lack of impulsive behaviors, as well as improved cooperation with staff with regard to daily functioning. There were no general medical issues or co-occurring substance use disorders complicating this case that would have required the continued acute inpatient level services. Additionally, the inpatient stay 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 treatment in the community. Thus, mental health 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.