Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Mental Health.
Treatment:  Mental Health Inpatient.
The health plan denied the mental health inpatient stay.  The denial was overturned.

The patient is a female admitted to acute inpatient psychiatric services for an exacerbation of a chronic psychotic disorder best characterized as schizoaffective disorder, depressed type.  The patient had shown increasing symptoms of psychosis following discontinuation of her oral medication with onset of bizarre delusions and erratic behavior, disorganized thoughts with paranoid thinking together with motor agitation, and increasing responses to internal stimuli that included command auditory hallucinations.  She was brought to the emergency department and was subsequently admitted after medical clearance that included physical examination, laboratory assessment and drug screen.  Her assessment included no abnormal or remarkable laboratory findings including a negative drug screen consistent with her history.

The patient's treatment plan included safety monitoring and medication targeting mood disturbance and psychosis, as well as the opportunity for therapy and psycho-education provided in the therapeutic milieu.  The patient was cooperative but guarded.  The patient continued to display severe symptoms of psychosis with essentially no change in her mental status examination, and continued response to auditory hallucinations.  She had received 400 milligrams (mg) of Abilify Maintena on prior to admission, and there were plans for continued use of Abilify supplemented with antipsychotic medication with Cogentin and Prozac, with as needed (prn) use of Haldol and Ativan for agitation and Benadryl for insomnia.  The patient remained psychotic with continued evidence for affective instability with hopelessness, helplessness, and dysphoric mood, odd behavior, and responses to internal stimuli including command auditory hallucinations telling her to refuse medications and indicating that she was at risk for harm from others.  She continued to display guarded behavior and was restless requiring prn medications and medication changes including the use of olanzapine and trazodone at night.  She continued to attend to internal stimuli and was socially isolative.

Six days into the stay the patient gradually became more at ease and was more receptive to participating in educational groups and other group sessions focusing on social skills with ongoing monitoring and development of a relapse prevention plan focusing on medication compliance/adherence.  She received an injection of Abilify Maintena on with plans for continued treatment in the community with assertive community treatment (ACT).  Case management was involved in developing a safe and clinically appropriate discharge plan that included discharge to a women's shelter and continued social services, as well as resumption of ACT level treatment.  She was discharged, at which time she was no longer deemed to be a danger to herself or others and had resolved her auditory hallucination with improved mood and diminished anxiety and better control of impulses and ability to comply with treatment.

The health plan's determination is overturned, in whole.

The patient's continued hospital stay for treatment of an exacerbation of a psychotic and mood disorder (schizoaffective disorder, depressed type) associated with non-adherence and non-compliance with outpatient treatment and risk for suicidal behavior did warrant the continued stay through discharge.  The patient's severity of symptoms, and the treatment refractory nature of her psychotic and mood disorder, as well as the patient's inability to benefit from treatment at a lower level of care, functional decline, and safety issues related to persistent symptoms of psychosis and mood disturbance, were clinical factors and treatment dimensions that warranted the continued acute inpatient hospital care, structure, and monitoring as proposed through discharge.

The medication adjustments and safety monitoring together with attention to the compliance issues in this case were medically necessary in this case scenario; the intensity of services and safety issues related to erratic/catatonic behavior and affective instability could not have been effectively addressed or managed at a lower level of care during the time interval under review.  The additional inpatient treatments including medication adjustments, evidence-based psychosocial therapy and other therapeutic interventions to address reality testing and social skills were medically necessary in order to continued active treatment, and to develop a safe and clinically appropriate discharge plan and disposition.  Treatment also included monitoring the response to medication adjustments as well as the work with community providers for a step down to ACT level care and continued use of a long-acting injectable antipsychotic medication.  All of these were clinical factors and treatment dimensions that did require the continued inpatient mental health stay.  Thus, medical necessity is met in this case.