Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Depression, nightmares, flashbacks

Treatment: Inpatient Psychiatric Services 

The insurer denied coverage for Inpatient Psychiatric Services. The denial was upheld.

This patient is a male who was admitted to this inpatient mental health treatment in this hospital in late 2018 after being administratively removed from inpatient substance rehabilitation, after it was reported that he was hoarding Suboxone. He was discharged from jail, prior to that rehabilitation treatment. He had a history of heroin and cocaine use.  He had depressed mood, flashbacks and nightmares regarding finding his son after his suicide incident, one year prior to admission, and reported that he did not want to live, although he did not report a specific plan or intent. He was prescribed the following medication: Suboxone, Bupropion, and Propranolol. He was discharged back to the custody of his parole officer. He had reported diagnoses of Major Depressive Disorder, Post-Traumatic Stress Disorder (PTSD), Attention Deficit Hyperactivity Disorder (ADHD), and substance use disorder.

The insurer denied coverage for inpatient mental health treatment in this hospital, as not medically necessary treatment. They stated that he did not require 24 hour hospital treatment as he had no reports of suicidal intent or plan. They recommended a less restrictive level of care.

The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Major Depressive Disorders reports that the least restrictive level of care for safe and effective treatment is appropriate and that patients with suicidal plan or intent or behaviors, or inability to adequately care for basic needs are candidates for hospitalization. In this case, this patient had reports of suicidal ideation without plan or intent and had no reports of past suicide attempts.  
Notes reported that he was seeking more Suboxone and denied suicidal thoughts, plans, or intent, and had okay mood. Also notes reported that he was doing okay, denied specific issues, had no significant distress, was calm and denied suicidal or homicidal ideation, hallucinations, hopelessness, helplessness, or worthlessness, and his mood was okay. One note specifically reported that his anxiety was better with Propranolol; he had no suicidal or homicidal ideation, hallucinations or hopelessness. He was interacting with others, in no distress, but was found snorting a white substance which he stated was sugar while in his room. Per the notes, it seemed that he came to this hospital to try to avoid legal consequences after being removed from past inpatient substance rehabilitation treatment. It also reported that he denied suicidal ideation, plan, or intent, and was not an acute risk. There were no reports of specific identifiable or quantifiable treatment goals or objectives that could only be achieved in a 24 hour acute psychiatric hospital setting or that could not be achieved in a less restrictive setting.
 
As a result, the determination is to uphold the previous decision and deny coverage for inpatient mental health treatment.  It appeared that the health care plan acted reasonably and with sound medical judgment and in the best interests of the patient.

The carrier's denial of coverage for the inpatient psychiatric services is upheld. The medical necessity is not substantiated.