Appeal type: Medical necessity
Decision: Overturned

Mental Health - Depression
Mental Health Inpatient

The patient is a female admitted for acute inpatient psychiatric care. The patient presented with worsening symptoms of depression, suicidal ideation with plan to hang self or cut or jump in front of a train. She had comorbidity that included eating disorder and trichotillomania with skin picking, and severe psychosocial stressors that include childhood sexual and physical abuse, as well as social isolation and a decline in functioning. She had failed to benefit from multiple medication trials and outpatient therapy and had two recent partial hospital program (PHP) stays with persistent symptoms. Again, her clinical presentation was complicated by an unspecified eating disorder that had included restricted intake, and binge eating with purging and laxative abuse. At the time of presentation, the patient was anxious and dysphoric with hopelessness, worthlessness and prominent suicidal thoughts. She had diminished sleep, appetite, energy, concentration and volition. There were no symptoms of mania, thought disorder, psychosis or severe cognitive impairment. However, the patient did endorse auditory hallucinations and was noted to have poor control of impulses and urges to self-harm with cutting, as she had a history of self-injury with cutting and attempts at asphyxiation with wrapping a cord around her neck.

The patient has a history of a depressive disorder, obsessive compulsive disorder (OCD), eating disorder, and borderline personality disorder that had been treated with outpatient therapy and medications; she had received partial hospital program (PHP) services at least twice more recently. There was history of psychiatric hospitalizations and suicide attempt by overdose. There was trauma history with a sexual and physical abuse as a child with reports of flashbacks and nightmares that had worsened. She also had a history of hair pulling and skin picking, as noted, as well as self-harming behavior with cutting her thighs with a razor.

The patient received a comprehensive, psychiatric evaluation upon admission and was diagnosed with major depressive disorder, recurrent and severe with psychotic features and with borderline personality disorder as the primary diagnoses together with past history of comorbid conditions. The patient's treatment plan included safety monitoring, individual and group therapy, education, and medication as before with adjustments. There was also consideration of another course of electroconvulsive therapy that was subsequently dismissed due to the nature of her personality disorder and patient preference.

The patient was medication adherent and participating more actively in her treatment. She had intermittent suicidal ideation requiring safety monitoring and continued to endorse auditory hallucinations that were consistent with the borderline traits. She had improved mood and functioning with diminished anxiety. The treatment team had determined that the patient would require residential level aftercare, and plans were made for a safe and clinically appropriate discharge and disposition.

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

The patient's severity of symptoms, and inability to participate in treatment at lower levels of care, functional decline, and risk of relapse necessitated the continued acute inpatient care through discharge. The presenting and continuing symptoms of depressive disorder were not amenable to treatment at a lower level of care during the time interval under review, in view of the worsening depression while in outpatient treatment with high risk for suicidal behavior, disordered eating and maladaptive coping in association with borderline personality disorder. The patient's progress notes clearly indicate that the patient displayed continued symptoms that required inpatient level structure and monitoring with medication adjustments and evidence-based therapeutic interventions. Specifically, she remained anxious with persistent symptoms of the borderline personality disorder requiring medication adjustments and intensive psychotherapy and counseling. Moreover, the patient continued to experience severe bouts of anxiety/irritability, and other symptoms that would necessitate inpatient level psychiatric services with continued symptoms of severe and recurrent major depression and borderline features that required ongoing safety monitoring with a safe and clinically appropriate step down to residential level care.