Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Symptoms of Depression (Thoughts of Suicide)
Treatment: Continued Inpatient Mental Health Treatment with 24-Hour a Day Nursing Support

The insurer denied the Continued Inpatient Mental Health Treatment with 24-Hour a Day Nursing Support.

The denial is upheld.

The patient is a female who was admitted to the acute inpatient psychiatric unit. She was diagnosed with major depressive disorder, recurrent, severe without psychotic features (F33.2). The patient was admitted for worsening symptoms of anxiety, depression and suicidal ideations in the context of significant psychosocial stressors.

The patient was noted to have a significant history of psychiatric treatment in the past including multiple psychiatric hospitalizations and trials of several psychotropic medications. Most recently, the patient was reported to have been admitted to an acute inpatient psychiatric unit. She was reported to have a history of suicide attempt in the past. There was no indication of the patient having any significant history of substance abuse. She was not reported to have any significant ongoing medical conditions that required hospital-based interventions or monitoring at the time of admission. The patient was reported to have a history of nephrogenic diabetes from treatment with lithium.

The patient was noted to be largely stable with no significant acute behavioral symptoms. There was no indication of the patient continuing to have active suicidal or homicidal thoughts with plans or stated intent. Clinical documentation reviewed does not indicate that the patient continued to be at imminent risk of harm to herself or others. The patient was not reported to have any symptoms suggestive of command hallucinations, persecutory delusions or extreme paranoia. She was not reported to have exhibited any significant agitation or aggression while on the inpatient unit. There was no indication that the patient could not continue electroconvulsive therapy as an outpatient.

The patient had no significant ongoing medical problems that required hospital-based interventions. She was not reported to have any functional impairments including activities of daily living and self-care. She was not reported to have had any significant adverse effects from medications. She was not reported to have any significant withdrawal symptoms from substances that required inpatient monitoring or management. The patient was not reported to have any significant deterioration or emergence of new symptoms. The patient was discharged to continue outpatient treatment.

Based on current evidence-based medical literature, the requested service acute inpatient behavioral health level of care through discharge is not medically necessary. The clinical information provided does not indicate that the service requested was the least restrictive setting that was medically necessary or was likely to be successful in treating the patient's symptoms.
Based on current peer reviewed, evidence-based medical literature, the requested service (behavioral health inpatient stay) was not found to be medically necessary. The clinical information provided does not indicate that the service requested was medically necessary or likely to result in further improvement of symptoms (1-8). 

The patient was noted to be largely stable with no significant acute behavioral symptoms the start of the dates of service in question. There was no indication of the patient continuing to have active suicidal or homicidal thoughts with plans or stated intent. Clinical documentation reviewed does not indicate that the patient continued to be at imminent risk of harm to herself or others. The patient was not reported to have any symptoms suggestive of command hallucinations, persecutory delusions or extreme paranoia. She was not reported to have exhibited any significant agitation or aggression while on the inpatient unit. There was no indication that the patient could not continue electroconvulsive therapy as an outpatient.

Clinical documentation reviewed does not indicate that the patient had any significant ongoing symptoms that required acute inpatient psychiatric hospitalization with 24-hour medical and nursing care. 

The patient was noted to be largely stable and at her baseline with no significant ongoing behavioral health symptoms that required continuing treatment at the acute inpatient level of care. The patient was not noted to be at risk of harm to herself or others. She was not reported to have any ongoing symptoms suggestive of psychosis or mania. There was no indication of the patient had any significant functional impairments including activities of daily living or self-care that represented a change from her baseline. She had no ongoing medical conditions that required interventions or monitoring. The patient may have been treated safely and effectively in a less restrictive setting and lower level of care such as continued outpatient treatment. Continuing treatment proposed for the patient may have been provided safely in an outpatient setting. Therefore, the health plan was noted to have acted reasonably and with sound medical judgment, in the best interest of the patient in denying coverage for continued acute inpatient level of care through discharge.

The patient had no significant ongoing medical problems that required hospital-based interventions. She was not reported to have any functional impairments including activities of daily living and self-care that represented a change from her baseline. She was not reported to have had any significant adverse effects any prescribed medications. She was not reported to have any significant withdrawal symptoms from substances that required inpatient monitoring or management. The patient was not reported to have any significant deterioration or emergence of new symptoms. The patient may have been treated safely and effectively in a less restrictive setting and lower level of care such as continued outpatient treatment.