Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Suicide attempt, substance abuse
Treatment: Continued Inpatient Mental Health Stay
The insurer denied the continued inpatient mental health stay.
The determination is upheld.


The patient was brought in by the police after a suicide attempt with an overdose of Xanax and one bottle of Nyquil. The patient's sister had notified police of the suicide attempt. The patient's mood had recently worsened with increased anxiety, depression and sleep disturbance in the context of substance use and a pending divorce. The patient has co-occurring substance use disorder with cocaine, cannabis, and alcohol with benzodiazepine use and tobacco dependence. The patient's reported ongoing stress with regard to primary support, social, occupational and daily functions. He reported a history of a myocardial infarction and atrial fibrillation and other chronic medical conditions including obesity and metabolic syndrome, as well as a recent injury to his left foot. He was medically screened and admitted to inpatient psychiatric care.

His past history included psychiatric hospitalizations and substance use disorder treatment with a chronic relapsing course. He had a longstanding mood disturbance together with marital problems and a past history of legal problems.

Mental status examination on admission included a disheveled male, appearing older, and with poor eye contact and a cooperative stance. His mood was depressed and irritable with anxious affect and sleep disturbance. His thought processing was linear with no evidence of psychosis, mania, thought disorder, or severe cognitive impairment. The patient denied suicidal ideation despite the attempt and subsequent calls to his mother threatening suicide with fair to poor insight and impaired judgment.

The patient was assessed with a comprehensive psychiatric and psychosocial evaluation. Medications were provided to include Zoloft and Remeron with adjustments to address insomnia and anxiety-related symptoms with as needed (prn) use of hydroxyzine for insomnia. The patient had the opportunity to participate in group, educational and milieu activities including educational sessions aimed at assisting the patient with improved coping skills and abstinence from substances. The patient received a tapering regimen of Librium with mild withdrawal symptoms and the patient had the availability of comfort medication and was prescribed supplements including vitamins and nicotine replacement.
The patient was compliant with his treatment plan and adherent with medications with tolerability. The patient remained depressed with irritability. He had attempted to elope on the day of admission and subsequently had called his mother threatening suicide, as noted. He also attacked another patient for reasons unknown.

He displayed improved mood with brighter affect and better sleep and functioning. He had fair insight, but impaired judgment, as before. He was future oriented with a more positive outlook, and was receiving support from his mother. He was attending groups and considering treatment for the substance use disorders. He remained on Zoloft 50 milligrams (mg) and Remeron was increased to 30 mg. An orthopedic consultation had been obtained with recommendation for a boot on his left foot.

There were no further complications of treatment or the clinical course during his inpatient stay. By the date of discharge, he was noted to be calm and cooperative, still with improved mood and diminished anxiety and better sleep. Insight was improved. Throughout the inpatient stay, he had denied suicidal ideation and there were no remaining safety concerns. He was discharged with clinically appropriate aftercare including referral to his community provider of services for medication management and recommendations for substance use disorder treatment. The health plan documents, the case records, and correspondence from the health plan and treatment facility were reviewed. The rationale for denial of the requested benefit of inpatient level mental health stay was reviewed.

The issue under review is continued inpatient mental health stay.

The requested health service/treatment of inpatient mental health stay was not medically necessary for this patient.

Continued inpatient level monitoring for safety and the structure of the residential setting was not medically necessary in this case scenario. The patient could have received intensive mental health services with lower level care in keeping with prevailing standards of medical practice. His family was supportive and the marital issues and other psychosocial issues as well as the substance use disorders could have been effectively addressed at a lower level of care. The patient's psychosocial stressors were not so severe to prevent treatment from continuing at a lower level of care with more intensive services. The patient had access to 12-step recovery groups and medication-assisted treatment for the substance use disorders. Thus, the requested benefit of inpatient level mental health stay was not medically necessary in keeping with prevailing standards of medical practice and the guidelines and American Society of Addiction Medicine (ASAM) Criteria referenced below, as well as the application of NY State Office of Alcoholism and Substance Abuse Services (OASAS) Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) Criteria, also referenced below.