Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Unspecified Depressive Disorder

Treatment: Inpatient Behavioral Health Level of Care, Adult

The insurer denied coverage for Inpatient Behavioral Health Level of Care, Adult

The denial is overturned.

This adult female was admitted to inpatient hospital treatment due to severe depressive symptoms including a recent suicide attempt a few days prior to admission, depressed mood, suicidal thoughts, mood swings, and multiple substance use including alcohol. She reportedly was drinking 6-8 beers per day, using Xanax, Adderall, cocaine, hallucinogens, ketamine, and cannabis. She reportedly had diagnoses of Unspecified Depressive Disorder, Alcohol Use Disorder, Stimulant and Cannabis Use Disorder. She reportedly was in treatment with an outpatient psychiatrist for months. She was taking Desvenlafaxine, Lamotrogine, Trazodone, and Quetiapine. She attended group and individual psychotherapy and was in relational mentalization based therapy. 
  
The medical records provided enough specific evidence to support that the patient required inpatient level of care. The Milliman Care Guidelines (MCG) Behavioral Health Inpatient Level of Care Adult criteria reports that a patient needs to present as an imminent danger to self, imminent danger to others, with severe psychiatric or behavioral symptoms, have a severely dysfunctional living including inability to care for self, unwillingness to participate voluntarily, or a less restrictive level of care is not feasible meet criteria for inpatient behavioral health level of care. InterQual Behavioral Health-Adult Psychiatry-Inpatient medical necessity criteria reports that if one has assaultive behavior within 24 hours, catatonia, command hallucinations to harm self or others, destruction of property with poor impulse control within 24 hours, disorganized behavior, unstable eating disorder, fire setting, homicidal or suicidal attempt within 24 hours, suicidal or  homicidal ideation with high risk for an attempt, mania, risk of harm to self or others, non-suicidal self-injury and continued danger to self, positive psychotic symptoms with risk of harm to self or others, post-traumatic stress disorder (PTSD) with risk of harm to self or others , psychomotor agitation and potential for violence, severe social withdrawal and refusing treatment, unavailable support or inability to provide needed care and supervision and there is acute deterioration, then one still meets criteria for hospital treatment.

In this case the patient was considered at high-risk for suicide due to the recent suicide attempt in the context of severe depression, increased alcohol use and multiple serious substances of use including using Xanax, Adderall, cocaine, hallucinogens, ketamine, and cannabis, as well as stressors including the overdose of a friend and strained family relations. She reportedly made the suicide attempt while under the influence. It was reported that she had limited insight and poor judgment and needed improvement in her coping skills and problems solving skills. 

The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Suicidal Behaviors reports also that patients may require more time in the hospital to better assess suicide because they sometimes do not tell the truth regarding their suicidal thoughts in order to leave the hospital and that observation in the hospital is appropriate to better ensure their safety. This patient was considered a high-risk patient with a recent suicide attempt prompting this admission and had reports of severe depression, poor judgment, multiple stressors, and significant alcohol and substance use which put her at even higher risk of harm to self. 

The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for the Inpatient Behavioral Health Level of Care, Adult, is overturned. Medical Necessity is substantiated.