Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Bipolar Disorder, Current Episode Depressed, Severe, without psychotic features 

Treatment: Inpatient psychiatric treatment

The insurer denied coverage for inpatient psychiatric treatment. The denial was reversed.

This patient is a male admitted for acute inpatient psychiatric treatment.  He was diagnosed with Bipolar Disorder, Current Episode Depressed, Severe, without psychotic features. The medical record indicates the patient indicate that he was hospitalized after attempting suicide by cutting his wrists with a box cutter.  He reported being severely depressed.  He reported hopelessness in the context of family and financial stressors as well as homelessness.  He reported several months of cycling between mania and depression.  There was information that he went to train tracks but he denied this was a result of suicidality.  He had a history of multiple hospitalizations over the previous months, and he had been discharged from a prior hospitalization. On admission his medications were reported as Depakote and Abilify.  Upon admission he denied suicidal or homicidal ideation or intent.  He was guarded.  Following admission he was Abilify and Depakote.  Notes over the next several days document the patient reported ongoing depression, helplessness and hopelessness.  He was noted to be isolating, withdrawn, with deteriorated functioning.

On a specified date he was prescribed Zyprexa.  As of another date it was documented that the patient was going to most groups and unit activities, was friendly but asocial, had organized thinking, and euthymic mood.  He was compliant with medication treatment and he denied suicidal ideation.  He continued to be improved with some variation in his mood over the next week.  He began to be screened by housing programs. He began to show increased irritability with verbal outbursts, intrusiveness, behavioral agitation, and sexual disinhibition; he was treated with Zyprexa, Risperdal (with plan to use long acting injectable medication), Depakote, trazodone, and Prozac. He continued to report a mixture of depressive and manic symptoms, and the patient's brother expressed concern regarding his suicide potential.  Over the course of the next two weeks he continued to have symptoms of depression and was continually assessed as being unable to be safely discharged without a comprehensive treatment plan which was not able to be affected.  He continued to display depressive symptoms and a flat affect.  Application was made for transfer to a long-term hospital setting.   

The health plan did not act reasonably with sound medical judgment. Based upon the information available the patient medically required ongoing acute inpatient psychiatric care until a long term care transfer could be accomplished; as such the insurer's denial of coverage for inpatient psychiatric treatment is reversed. He had ongoing symptoms of Bipolar Disorder and was assess as being at high suicidal risk if outside a hospital setting. His treatment team made appropriate efforts to reduce his symptoms such that a discharge could be affected, and once they determined that this was not likely to happen they effected an involuntary commitment and pursued long-term hospitalization.  Until such time as the patient is able to be transferred to a long-term care hospitalization he requires ongoing acute treatment.  It would have been unsafe to discharge the patient to a lower level of care in the interim.

This finding is consistent with the general standards of psychiatric care, the APA Guidelines for the Treatment of Patients with Bipolar Disorder, and InterQual Behavioral Health Criteria 2018 Adult and Geriatric Psychiatry, Hospitalization, Psychiatric, Adult, Mental Health Criteria.  

Based on the above, the medical necessity for the inpatient mental health treatment is substantiated.  The insurer's denial is reversed.