Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Suicide attempt. 
Treatment: Continued inpatient mental health treatment. 

The insurer denied coverage for the continued inpatient mental health treatment. 

The denial is modified. 

This is a transgender female (male-to-female) patient who was admitted to inpatient mental health treatment due to suicide attempt by overdose and she reportedly had depressed mood, poor impulse control and coping skills, and multiple past psychiatric hospitalizations. She was unemployed. She had a diagnosis of Bipolar Disorder II-depressed and took Quetiapine. She was discharged on day 59 of admission. 
  
The insurer denied coverage for continued inpatient mental health treatment in this hospital from day 48 of admission to day 59 of admission as not medically necessary treatment then. They stated that she did not present as an imminent danger to self or others and did not require further hospital treatment. They recommended a less restrictive level of care then. This reviewer disagrees with the decision to deny coverage for continued inpatient mental health treatment in this hospital from day 48 of admission to day 50 of admission but agrees with the decision to deny coverage for continued inpatient mental health treatment in this hospital from day 51 of admission to day 59 of admission as the medical records provided reported that she still had suicidal ideation and self-harm thoughts and depression until day 50 of admission but not as of day 51 of admission. 

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 for suicide. Past suicide attempts are the single most reliable predictor of suicide. This patient was considered an at risk patient while still reporting suicidal ideation due to her serious suicide attempt on admission. The medical records from day 51 of admission no longer provided enough specific evidence to support that the patient still required 24 hour hospital treatment after that. As of day 51 of admission there were no reports of suicidal or homicidal ideation, intent, or plan, inability to adequately care for basic needs, manic episodes, psychotic symptoms, self-injurious, aggressive, threatening, or agitated behavior, specific evidence that she was an imminent danger to self or others or unable to adequately care for her basic needs. Also, as of then 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 modify the previous decision and approve coverage for continued inpatient mental health treatment in this hospital from day 48 of admission to day 50 of admission but deny coverage for continued inpatient mental health treatment in this hospital from day 51 of admission to day 59 of admission.  It appears that the insurer acted reasonably, with good clinical judgment, and in the best interests of the patient from day 51 of admission to day 59 of admission but not from day 48 of admission to day 50 of admission. 

The insurer's denial of coverage for the continued inpatient mental health treatment from day 48 of admission to day 59 of admission is modified as noted above. Medical necessity is partially substantiated.