Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Intentional suicide attempt via overdose
Treatment: Inpatient admission
The insurer denied coverage for: Inpatient admission
The denial is: Overturned
The adult patient was admitted to this inpatient hospital after an intentional suicide attempt via overdose of 15 Seroquel pills while drinking wine. The patient got into an argument with significant other who wanted the patient to leave the house. It was reported that the patient was evasive, minimizing the situation, and was considered an imminent danger to self. The patient reportedly had a diagnosis of cocaine and alcohol abuse and had a Drugs of Abuse in Urine Scheme (DAU) positive for cocaine. The patient was seen by the Psychiatric consultant who did not clear the patient psychiatrically. The patient also had a blood alcohol level (BAL) of 117 and was put on a Clinical Institute Withdrawal Assessment (CIWA) protocol including Ativan (prn) as needed. The patient reportedly had a poison control consult.  The patient also was on continuous telemetry, seizure precautions, had intravenous (IV) fluids, Thiamine, Lovenox, lab monitoring, and constant observation due to the suicide attempt. The patient was cleared by psychiatry and medically and was discharged with referral to outpatient mental health treatment.
 
This reviewer disagrees with the decision to deny coverage for inpatient hospital treatment. The medical records provided enough specific evidence to support that the patient required this level of care. The Milliman Care Guidelines (MCG) Drug Ingestion or Overdose criteria reports that one meets criteria if one of the following are met: Hemodynamic instability, dangerous arrhythmia, respiratory abnormalities, hypertension requiring inpatient treatment, specific finding indicating severe and prolonged drug toxicity, or inpatient admission is required other than observation care. Also, the American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Suicidal Behaviors reports that patients with suicide attempts are at high risk of suicide. Suicide attempts are the single most reliable predictor of suicide. It also states that patients with substance use are at increased risk for suicide. This patient was considered an imminent danger to self-due to an intentional overdose. Also, the MCG General Admission Inpatient criteria reports that one meets criteria for inpatient admission if one is actively suicidal or if one presents as a danger to self. In this case this patient had reports of an intentional suicide attempt by overdose of 15 Seroquel pills while drinking wine after an argument with significant other, so there was active suicidality and was considered an imminent danger to self-requiring 24-hour inpatient hospital treatment. The patient had other risk factors including using cocaine and alcohol which put the patient at higher risk for suicide. The patient also had medical issues including being put on a CIWA protocol for potential alcohol withdrawal, had elevated ammonia of 62, and prolonged QT's interval of 430 on the electrocardiogram (EKG) which put the patient at risk for cardiac arrhythmias. The patient had a past medical history of depression and asthma. It was reported that the patient remained with suicidal ideation and that safety precautions needed to be resumed as a result, so psychiatry did not clear the patient as the patient was still considered a danger to self and needed 24-hour hospital treatment. It was reported that the patient was evasive, minimizing the situation, and was considered an imminent danger to self. 

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for the inpatient admission is substantiated.