Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Paranoid schizophrenia.
Treatment: Inpatient Mental Health Stay.
The insurer denied Inpatient Mental Health Stay.
The determination is partially overturned.


The patient was admitted to inpatient psychiatric care. He presented with agitation and aggressive behavior directed towards his mother with whom he lived. His mother activated emergency services who brought the patient to the emergency department. He was noted to have an exacerbation of his underlying psychotic disorder, paranoid schizophrenia, with a past history of comorbid autism spectrum disorder. The patient was disorganized, delusional, and motor agitated with irritable mood and labile affect, and with poor insight and impaired judgment together with aggressive impulses and delusional thinking. He had stopped his psychotropic medications and was known to be non-compliant with outpatient treatment.
The mental status examination revealed a disheveled appearance with poor hygiene and with motor agitation and uncooperative stance. He displayed disorganized and circumstantial thought processing and markedly impaired judgment together with a lack of insight. His speech was slow and fluent. Mood was dysphoric and irritable with labile affect. The patient was illogical and concrete.
There was no substance use disorder or acute general medical issues in this case. The patient was chronically ill with diabetes mellitus, dyslipidemia, and gastroesophageal reflux disease (GERD), as well as his functional impairments and exacerbation of the chronic psychotic disorder. He had a history of multiple inpatient psychiatric admissions and aggressive behavior.
The patient was admitted to inpatient level services with medical clearance. He received acute inpatient level psychiatric services with close observation and pharmacotherapy that included continued the use of Abilify. His hospital course was complicated by severe symptoms of psychosis and thought disorder that persisted throughout his stay. The patient was resistant to taking medication and refused long-acting antipsychotic medication. He tended to isolate socially with continued bouts of agitation and irritable mood.
The patient remained irritable with illogical thought and delusions, but the patient was medication adherent with oral medications that included Abilify, Metformin and Simvastatin. He rarely participated in milieu activities, but was increasingly more cooperative with staff.
He became increasingly calm and cooperative with improved mood and functioning, better sleep and appetite and self-care. Planning was in place for referral to an Assertive Community Treatment (ACT) team for intensive case management and services in the community, as well as safety measures in the home. The patient remained cooperative with more organized thought processing and fair impulse control. He denied suicidal ideation or aggressive impulses. He was medication adherent with tolerability though refusing long acting injectable (LAI) medication. There were no general medical complications during his inpatient stay. He was discharged to the home of his mother.
At issue is the medical necessity of Continued Inpatient Mental Health Stay.

The inpatient stay is medically necessary in part. The requested health service/treatment of inpatient mental health treatment is medically necessary for this patient, except for the last 7 days of the stay.

The continued acute inpatient mental health treatment was clinically appropriate and medically necessary for this patient. The requested benefit of acute inpatient psychiatric care was appropriate to the diagnosis, and was necessary with regard to the level of care, the structure, the intensity of services, and the monitoring required to safely and effectively manage the patient's acute psychosis and chronic psychotic disorder, problematic behaviors and general medical comorbidities.
The patient displayed psychotic symptoms in the context of functional impairment and bouts of hostility, anger, tension and excitability in the context of disorganized thought processing and illogical and delusion thought content, as well as mood disturbance with persistent irritability. He had impaired judgment and a lack of insight. The patient continued to require ongoing direction and assistance from staff while receiving active treatment that was being provided to support reality testing and improve his functioning and coping skills. He had not shown the improvement that would allow him to safely receive treatment with lower level of care services for the time interval. Thus, the patient did require continued acute inpatient level monitoring and structure while developing a plan for continued psychiatric care with a safe and clinically appropriate disposition.
However, for the last 7 days, the patient's mental status had improved and he was functioning better, as noted in the clinical summary and documentation provided, and recommendations for continued care had been finalized. The patient no longer required the structure of an acute inpatient level of care in order to remain safe or to receive ongoing support of daily activities and safety monitoring. It was not medically necessary for this patient to have continued acute inpatient level services  in view of his relative lack of impulsive behaviors and cooperation with staff with regard to daily functioning. There were no general medical issues or co-occurring substance use disorders complicating this case that would have required continued acute inpatient level services. Also, the patient had no plan or intent of self-harm, or persistent impulsive or erratic behaviors that placed him at imminent risk for harm to self or others.
This answer is consistent with prevailing standards of medical practice and the scientific literature and guidelines, referenced below.