Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Bipolar Disorder
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial was overturned.  

This is a female patient with a psychiatric history of Bipolar Disorder and Substance Use Disorder. She was transferred from a medical unit where she had been treated for pneumonia to inpatient psychiatric unit due to depressive and anxiety symptoms, suicidal ideation with plan to end her life, recent violent behavior, hopelessness and helplessness, and anxiety. The patient reportedly was using multiple substances and had a positive toxicology for cocaine, opiates, and benzodiazepines. Her medical treatment included Seroquel, Lexapro, Tegretol, and Buspirine and individual supportive treatment. The patient was then discharged to a substance rehabilitation treatment.

The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Bipolar Disorders reports that the least restrictive level of care for safe and effective treatment is appropriate and also that patients with severe agitation, aggression, psychotic symptoms, suicidal or homicidal plan or intent or attempts, manic episodes, severe major depressive episodes, or inability to adequately care for basic self-care needs are in need of hospital treatment. In this case, this patient had continued reports of severe depressive symptoms during the denial period and also reportedly was considered a high risk of relapse for cocaine, opiates, and benzodiazepines if not transferred to a 24-hour inpatient substance rehabilitation treatment upon discharge.  The patient was considered a high risk for overdose.  It was reported that the patient was severely depressed with dysphoric mood, feelings of hopelessness and helplessness, and she was isolative with impaired attention. Notes reported that the patient was still hopeless and helpless with anxiety and depressed mood. Notes reported that the patient was depressed and anxious but less. It also reported that she could not manage on her own and was awaiting placement to inpatient substance rehabilitation facility. The patient found placement at which point, the patient was discharged and transferred for inpatient substance rehabilitation treatment. 

Based on the review of the medical record a literature, this was a high risk patient who had severe depressive symptoms and suicidal ideation in conjunction with multiple substance use including cocaine, opiates, and benzodiazepines. The patient was at high risk for relapse and overdose if not appropriately transferred to a 24-hour structured and supervised treatment setting upon discharge. According to the APA Practice Guidelines for the Treatment of Patients with Suicidal Behaviors, patients with hopelessness, bipolar disorder, and substance use are at higher risk for suicide. This was the case for this patient who continued to report depressive symptoms including depressed and hopelessness throughout the inpatient stay. Thus, inpatient hospital treatment was medically necessary for this patient.  

The health plan did not act reasonably with sound medical judgment, and in the best interest of the patient.

The carrier's denial of coverage for inpatient mental health treatment should be overturned. The medical necessity is substantiated.