Appeal type: Medical necessity
Decision: Upheld


Diagnosis: Depression 
Treatment: Inpatient admission
The insurer is denied coverage for the inpatient admission.
The denial is upheld.

This is a male patient who has a history of alcohol, crack/cocaine, cannabis use, and suicide attempt by cutting his wrist resulting in a psychiatric hospitalization. He was admitted to this inpatient mental health treatment due to worsened depression. His symptoms included suicidal ideation with a plan to jump off the roof or hang self, hopelessness and helplessness, paranoid delusional thinking, thought blocking, poor activities of daily living and poor eye contact, noncompliance, irritability, and hostility. His medication included Wellbutrin and Risperidone. After a period of medical stability he was discharged.
The insurer denied coverage for continued inpatient mental health treatment in this hospital as not medically necessary treatment. They stated that he was not an imminent danger to self or others and did not require further 24-hour hospital treatment. They recommended a less restrictive level of care.
This reviewer agrees with the decision to deny coverage for continued inpatient mental health treatment in this hospital as the chart notes did not provide enough specific evidence to support that he only required 24-hour acute psychiatric hospital treatment or that he could not be treated in a less restrictive level of care. 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 aggression, homicidal or suicidal intent, plan, or behavior, psychotic symptoms, or severe agitation are candidates for inpatient hospitalization. In this case, this patient had initially presented with suicidal ideation and a plan to jump off the roof or hang self. He had depressive symptoms and psychotic symptoms including depressed mood, hopelessness and helplessness, paranoid delusional thinking, thought blocking, poor activities of daily living, poor eye contact, noncompliance, irritable mood, and hostility. However, he did not have reports of further suicidal ideation, plan, or intent.
Notes reported that he denied suicidal or homicidal ideation or hallucinations and there were no further reports of severe psychiatric symptoms requiring further psychiatric hospital treatment. Notes reported that he denied suicidal or homicidal ideation and there were still no reports of severe psychiatric symptoms requiring further psychiatric hospital treatment. Notes reported that he denied suicidal or homicidal ideation or hallucinations and had no behavioral issues. Notes reported that he was discharged.
There were no reports of severe depressive symptoms, suicidal ideation, plan, or intent, hallucinations or severe psychotic symptoms, homicidal ideation, plan, or intent, or severe agitation. There were no reports of acute medical instability or severe withdrawal requiring hospital treatment. There was no specific evidence that he was considered an imminent danger to self or others and there were no reports of specific identifiable or quantifiable treatment objectives that could only be achieved in a 24-hour acute inpatient hospital setting or that could not be achieved in a less restrictive level of care.
The insurer acted reasonably and with sound medical judgment and in the best interests of the patient.
Based on the above, the medical necessity for the continued inpatient hospital admission is not substantiated. The insurer's denial is upheld.