Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Schizoaffective Disorder
Treatment: Continued Inpatient Hospital Admission
The insurer denied the Continued Inpatient Hospital Admission.
The denial is overturned. 

The case involves a female with schizoaffective disorder, depressed type and co-occurring substance use disorder (cocaine and cannabis). She was admitted to acute inpatient level services with severe symptoms of depression and psychosis with auditory hallucinations, paranoid delusions and motor agitation. The patient's admission had been precipitated by worsening symptoms of depression in response to auditory hallucinations resulting in a 911 call and emergency medical services with presentation to the emergency department. The patient endorsed symptoms of depression, auditory hallucinations and paranoid thinking, and had been non-adherent to her outpatient medication-risperidone and Risperdal Consta.

The patient had a history of prior admissions for psychiatric treatment and had been in outpatient treatment for co-occurring substance use disorder and mental disorder. The patient had been non-adherent with medications and non-compliant with outpatient treatment in the context of active substance abuse with cocaine and cannabis, as well as intermittent use of alcohol. She was tobacco dependent at one pack per day.

There were no acute general medical issues in this case; and laboratory assessments were normal or unremarkable. The patient is obese and has chronic conditions including hypertension, eczema of the upper extremities, chronic constipation, and vaginosis that had been recently treated.

The patient was single and disabled, and she lived with family/mother and her children.

Mental Status Examination on admission: The patient was motor agitated, guarded, and psychotic with irritable and dysphoric mood and labile affect. She displayed depressed mood with anxiety and slowed mentation. She had decreased concentration, energy, appetite, sleep, and volition. Her speech was coherent with disorganized thought processing. She endorsed hallucinations, as noted and had paranoid thought content fearing the she and her children were at risk for harm. Insight and judgment were limited and impaired. 

The patient was admitted to acute inpatient level care after medical screening. The patient's treatment plan included safety-monitoring, access to group and milieu therapies, and resumption of medications, risperidone and Depakote. She received nicotine and vitamin replacement therapy. The patient was initially depressed, irritable, and socially withdrawn with the tendency to isolate in her room. 

The patient had resumed treatment with medications with tolerability. She remained depressed and socially isolated. The patient was increasingly cooperative with staff and medication adherent with titration to two milligrams (mg) of risperidone and 500 milligrams (mg) of Depakote twice daily; she still tended to isolate with social withdrawal and had begun to show participation in the therapeutic activities. Her auditory hallucinations had resolved, but she remained irritable with depressed mood and disorganized thought processing.  

A discharge plan was completed including plans for after care and return to her home with continued treatment in a dual diagnosis day program. At the time of discharge, the patient was better focused, calmer, and displaying better judgment with improved mood and brighter affect. Discharge occurred with clinically appropriate aftercare in collaboration with community providers to include mental health and substance use disorder services; and, primary care follow-up. Discharge medications included Depakote 500 milligrams twice a day (BID); risperidone two milligrams twice a day; and instructions to support smoking cessation with nicotine replacement therapy.

Yes, the proposed treatment, Continued Inpatient Admission and Stay for Mental Health Services, was medically necessary for this patient.

The patient's persistent symptoms of psychosis and mood disturbance together with continued risk of erratic behavior, and risk for non-adherence to medication prompted the necessity for continued acute inpatient level structure and monitoring through discharge. The case is complicated by active substance use disorder with crack cocaine and marijuana; and non-compliance with treatment and medication non-adherence. The residual symptoms of mood and psychotic disorder (schizoaffective disorder); co-occurring substance use disorder and treatment issues related to medication adjustments and arranging a safe and appropriate discharge plan warranted the continued services at an acute inpatient level of care. The Continued Inpatient Admission and Stay for Mental Health Services was therefore clinically appropriate and medical necessary, as the patient needed the inpatient level structure and 24-hour monitoring through the day of discharge when the patient had reached a level of stability that she could return home with clinically appropriate follow-up and aftercare.

This answer is consistent with the scientific literature and published practice guidelines, referenced below, as well as New York State instruction for medical necessity reviews and the application of NY State OASAS LOCADTR 3.0 Criteria (New York State Office of Addiction Services and Supports Level of Care for Alcohol and Drug Treatment Referral 3.0).

The Continued Inpatient Admission and Stay for Mental Health Services could not have been safely or effectively provided at a lower level of care. Thus, the requested benefit of Continued Inpatient Admission and Stay for Mental Health Services is reasonable and in the patient's best interest and is consistent with prevailing standards of medical practice for the treatment of the conditions diagnosed in this case.