Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Mental Health. 
Treatment: Mental Health: Inpatient. 
The insurer denied Inpatient mental health services. 
The denial was upheld in whole.

The patient is a male admitted to acute inpatient psychiatric services for treatment of major depressive disorder and generalized anxiety disorder associated with severe anxiety and concentration difficulties, as well as interrupted sleep resulting in daytime fatigue and irritability. The patient was referred for emergency care by his outpatient psychiatrist. The patient was evaluated at the time of presentation and was subsequently admitted for treatment with inpatient mental health/psychiatric services due to concern for suicidal risk and the worsening symptoms of anxiety and depression. There were no active substance use disorders, but the patient had a past history of cannabis and alcohol use disorders which were determined to be in early full remission. The patient also reported a history of obsessive-compulsive disorder (OCD). He was medically screened in the emergency department and cleared for admission to acute inpatient mental health services.
The patient was admitted to the acute inpatient psychiatric level of care with a diagnosis of major depressive disorder, generalized anxiety disorder and the past history of substance use disorder and OCD. He actively attended groups and other milieu activities receiving evidence-based psychotherapeutic interventions.
He continued to have intermittent passive suicidal ideation but was feeling better and denied a suicidal plan or intent. The patient was maintained on the psychotropic regimen with adherence and tolerability.
The patient wanted to remain in the hospital until he was 100% better according to progress notes, and there was concern for a relapse if discharged prematurely. Thus, the patient received continued inpatient treatment. A discharge plan had been developed in concert with the patient's spouse. He was discharged to home with a safety plan and with outpatient follow up arranged.
At issue is the medical necessity of Inpatient mental health services.

The health plan's determination of medical necessity is upheld in whole.

The requested health service/treatment of Inpatient mental health services is not medically necessary for this patient.
The continued treatment for the mental disorders in this case did not require the continued structure of an acute inpatient level of care or 24-hour monitoring. Specifically, the patient did not present with acute general medical complications, or active substance use. Following admission, the patient was treated for the mood disturbance and associated symptoms of anxiety/insomnia and functional impairments with clinically appropriate titration psychotropic medications with augmentation and other treatment that resulted in improvement in symptoms and functioning; he did not require continued acute inpatient level structure or monitoring during the time interval under review, as he was showing improvement and no longer considered a serious risk for suicidal behavior that would have warranted continued assessment, safety monitoring and treatment in an acute inpatient setting. The patient did not display continued evidence of active suicidal ideation, plan, or intent, and did not engage in self-harm during the hospital course; other symptoms such as severe cognitive impairment (dementia or delirium), thought disorder, mania or psychosis were not present in this case, nor was there symptoms of the psychiatric co-morbidity or co-occurring substance use disorders that would have warranted the continued acute inpatient level care. The patient had access to services in the community with the availability of continued treatment for his psychiatric disorders, and the patient had family supports and a discharge plan that was appropriate. 
Therefore, the requested health service/treatment of Inpatient mental health services is not medically necessary.