Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis:  Paranoid Schizophrenia 
 
Treatment:  Continued behavioral health hospital stay 

The insurer denied the Continued behavioral health hospital stay.  The denial was modified.  

This is a male patient with a history asthma, diabetes, hypertension, status post below knee amputation of the left leg, substance abuse, schizophrenia and schizoaffective disorder of past psychiatric hospitalizations.  He presented to the hospital due to his worsening psychotic symptoms.  His symptoms included disorganized and illogical thought process, paranoid delusional thinking, delusions, and auditory hallucinations, responding to internal stimuli, talking to self, poor self-care, impulsivity, and isolation.  It was reported that he was living in a homeless shelter and was noncompliant with outpatient psychiatric follow up.  He was treated with Risperidone and Depakote and was discharged to the Assertive Community Treatment (ACT) team.

The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Schizophrenia report that patients with hallucinations, delusional thinking, disorganized thinking or behavior, suicidal or homicidal plan or intent, agitation, or aggressive behavior, or inability to adequately care for basic needs are candidates for hospitalization.  In this case, this patient still had psychotic symptoms several weeks into his hospitalization.  Notes reported that he still had a disorganized and circumstantial thought process, persecutory/paranoid delusional thinking, and impaired judgment. Days later notes reported that he still had a disorganized thought process and that he had poor ADLs and poor grooming.  It was reported on a later date that he was talking to himself, had paranoid and persecutory delusional thinking, and was refusing medications; therefore, he was offered Risperidone Consta.  Notes on a later dates report he was talking to himself, had circumstantial and tangential thinking, delusions that he was King Tut, had poor insight, and delusions of reference, as he thought there was a system in his head telling him things.

Notes on a later date reported that he was still having the delusion that he was King Tut, was isolative, had poor ADLs, and poor insight.  A few days prior to his discharge there were no further reports of significant psychotic symptoms, severe depressive symptoms, homicidal or suicidal ideation, plan or intent, and there were no reports of specific identifiable or quantifiable treatment goals or objectives that could only be achieved in a 24-hour acute psychiatric hospital setting or that could not be achieved in a less restrictive setting.  

The carrier's denial of coverage for the continued stay in a behavioral health hospital is modified to approve the inpatient mental health admission until the date that there were no further significant psychotic symptoms, severe depressive symptoms, homicidal or suicidal ideation, plan or intent, and there were no reports of specific identifiable or quantifiable treatment goals that could only be achieved in a 24-hour acute psychiatric hospital setting or that could not be achieved in a less restrictive setting.