Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for inpatient hospitalization level of care for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that Based on the documentation provided for review, inpatient hospitalization level of care provided was medically necessary for treatment of the patients medical condition. The services provided from could not have reasonably been delivered effectively in a less restrictive setting while outpatient treatment would have resulted in inadequate care, increasing both patient morbidity and the chances of prompt re-admission. The patient has a prominent formal thought disorder impacting multiple domains and generating both robust intrapsychic distress and functional impairment. The patient had not yet consolidated the illness burden that prompted the admission. The patients treating provider continued to recommend inpatient services, According to the American Psychiatric Association, The psychiatrist should determine the least restrictive setting for treatment that will be most likely not only to address the patients safety, but also to promote improvement in the patients condition. Divalproex, a mood stabilizing agent that ultimately proved to be poorly tolerated, was added to high-dosed antipsychotic medication, olanzapine. The patient attempted a familiarity visit at an outpatient program, but lasted only five minutes in the group. The patient thought she was being poisoned and surveilled by cameras in the program. Upon returning to the unit, the patient was disturbed, paranoid and confused, and started on a second antipsychotic medication, haloperidol. The patient was agitated, paranoid and restless with no recollection of paranoia during visit to the outpatient program. The provider began a divalproex taper. The patient was anxious, uncomfortable and confused, and still had no recollection of paranoia during trials at the outpatient program. The provider discontinued the divalproex and increased the haloperidol.  The patient was restless and fearful of taking medications. The provider decreased the haloperidol, which was thereafter discontinued. In sum, the patient was still suffering from the illness burden that prompted the admission. The patient was engaged in active treatment with significant medication changes and discharge planning efforts. The inpatient team attempted a pre-discharge transition to an outpatient aftercare program to facilitate seamless transition to a less restrictive setting. Based on the documentation submitted for review that include progress notes and discharge summary, it is reasonable to assume that the during the remaining days the patient continued to work towards clinical stabilization and a successful discharge. During the disputed timeframe, the acute inpatient setting remained safe, appropriate and consistent with good medical practice and reasonably expected to both improve the patients condition and prevent a more serious episode of illness. Further, the duration of services was consistent with community standards for a case of this severity. Final Result: The reviewer determined that the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.