Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Mood Disorder.
Treatment:  Inpatient Mental Health.

The insurer denied the Inpatient Mental Health Stay.  The determination is overturned.

The patient was medically screened and admitted for acute inpatient psychiatric treatment in order to address worsening symptoms of a mood disorder and suicidal behavior.  The patient had become increasingly anxious and depressed with suicidal ideation and attempts to walk into traffic culminating in her presentation.  A break up initiated by her girlfriend had precipitated the recurrent depressive episode in the context of bipolar mood disorder.  She has a history of severe depressive episodes and psychiatric treatment with therapy and medications.  She had been hospitalized three times due to mood disturbance and suicide attempts.  Thus, her presentation was characterized by worsening symptoms of depression and suicidal behavior in the context of multiple psychosocial stressors that included the break-up of a one and one-half year relationship and elements of unresolved grief due to the death of her grandfather and her cat.  The patient had a history of a mood disorder and suicidal behavior with mood swings.  She was receiving outpatient psychiatric treatment with medications and therapy, and had history of psychiatric hospitalizations and three suicide attempts with an overdose, and other high-risk behaviors.

The mental status examination revealed a groomed female with clear and soft speech and circumstantial and excursive thought processing.  She was sad and tearful with anxiety including apprehension, nervousness, tension, irritability, and excessive worry.  She was cooperative with depressive demeanor, depressed mood and motor agitation.  Sleep, appetite, energy levels and volition were disturbed.  The patient expressed suicidal ideation, hopelessness, helplessness and worthlessness.  There was no psychosis or other signs of cognitive impairment or perceptual disturbance.  Her judgment was markedly impaired, and suicidal risk was judged to be moderately severe with poor control of impulses and limited insight together with her struggles with unresolved grief.  There were no acute or chronic general medical issues in this case, except for abdominal cramping of unknown etiology.  The patient was overweight and had been treated with metformin.

She was diagnosed with bipolar disorder with most episode depressed with severe symptoms, borderline personality disorder and the abdominal cramping.  The patient is single and a college student, and living on campus with two roommates, who were supportive.  She had support from family, her mother and sister, but had a strained relationship with her father.  There are no legal issues or trauma/abuse history reported in this case.

The patient was admitted to inpatient level-of-care with plans for close observation, safety monitoring, structured milieu therapy, and pharmacotherapy with continued use of lithium and Lexapro and discontinuation of Seroquel, and the addition of gabapentin and Abilify supplemented with as needed (PRN) anxiolytic medications for anxiety and insomnia (Vistaril and trazodone).  She was prescribed dicyclomine to address the abdominal cramps and gastrointestinal upset.

The patient settled into the inpatient milieu well but struggled with her mood disturbance and associated stressors.  She participated in group and individual sessions with cognitive behavioral and supportive techniques while maintaining safety.  Her participation in groups was inconsistent, but meaningful.  She had the opportunity for family focused sessions with her mother.  Grief counseling and psycho-education was provided.  Her medications were titrated as clinically appropriate with tolerability and adherence.

The patient continued to exhibit severe symptoms of depression with dysphoria and anxious affect.  Her medications were tolerated, as well as the use of a smart phone application in order to address bouts of anxiety and urges to self-harm.  During this time interval, she remained at risk for suicidal behavior with passive suicidal ideation; she showed slow improvement in mental status and functioning.  Dialectical behavioral therapy (DBT) and the medication therapies were provided to address borderline personality traits/disorder and the co-morbid mood disorder.  The patient gradually improved and became better engaged in therapeutic interventions and was more cooperative with staff and social with peers.

A family meeting was held to address discharge planning and consider an appropriate disposition.  The patient's mood was notably improved with diminished anxiety and improved functioning though she remained anxious with depression.  She denied suicidal ideation, plan or intent.  Insight, judgment and impulse control remained fair.

The patient was discharged from inpatient level care with step down to intensive outpatient level care with plans for return to her school and a safety plan including involvement in intensive DBT.  At issue is the medical necessity of continued acute inpatient mental health treatment.

The patient required the admission and the continued acute inpatient level care, and the continued structure of an acute inpatient level setting through discharge was warranted in order to provide safety monitoring and to administer treatment for the psychiatric disturbances while conducting an evaluation and while observing her functioning with the resumption/adjustment of clinically appropriate medications, including the use of evidence-based psychotherapeutic interventions and the use of a smart-phone application targeting anxiety and urges to self-harm.

The medical necessity for the continued acute inpatient level structure and monitoring was reasonable and in the patient's best interest in view of the patient's severe symptoms of mood disorder and co-morbid borderline personality disorder, in view of the severe psychosocial stressors that precipitated the presentation and recurrence of suicidal behaviors, and in view of the need for continued active treatment in the context of deteriorated functioning and the imminent risk for harm to self.

Additionally, the inpatient stay during the time interval under review was medically necessary in order to monitor the response to medications, to insure that the patient will have a sustained response to treatment, and to continue to address the acute risk of suicidal behavior in the context of severe symptoms of bipolar mood disorder with depression and the co-morbid borderline personality disorder that were only in partial remission.  The necessity for the continued inpatient level services reflects sound medical judgment in keeping with prevailing standards of professional practice, and with the published practice guidelines and criteria.