Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Major Depressive Disorder
Treatment: Inpatient mental health stay
The insurer is denied coverage for inpatient mental health stay.
The denial is partially overturned.

This is a female patient who was admitted to this inpatient mental health treatment due to a suicide attempt by overdose. She reported a depressed mood, worthlessness, poor energy, poor sleep, agitation, starting fights, self-injurious behavior including cutting her arm, and she had reports of dissociative episodes and past aggression including killing a cat and aggressive threats with a knife. She had Major Depressive Disorder, Posttraumatic Stress Disorder (PTSD), and Attention Deficit Hyperactivity Disorder (ADHD). Her hospital course of treatment and management included Gabapentin, Hydroxyzine, suicidal precaution, Zoloft, Sertraline, levothyroxine, ibuprofen, individual and group therapy. She was medically stable and discharged.

The insurer denied coverage for continued inpatient mental health treatment in this hospital as not medically necessary treatment. They stated that she had no suicidal or homicidal ideation or plan, self-harm behavior, or psychosis, and had no restraints or seclusion.

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 as past suicide attempts are the single most reliable predictor of suicide. It also reports that patients may require more time in the hospital to better assess suicide because they sometimes do not tell the truth regarding their suicidal thoughts in order to leave the hospital. They also note that observation in the hospital is appropriate to better ensure their safety. This patient was considered a high risk patient and benefitted from remaining in the hospital and being observed and assessed for safety, which was 2 days after last reporting suicide ideation with depression. Notes reported that she had suicidal ideation, sad mood, and was frustrated with being in the seclusion room. She reported that she dissociated during her last suicide attempt. Notes reported depressed and angry mood and concern regarding her dissociative episodes which involved suicide attempts and killing an animal in the past. Notes reported that she was overwhelmed, had self-injurious behavior including scratching her arm, and residential treatment was discussed. Notes reported that she had trauma nightmares, and psychological testing was recommended for dissociative episodes. Notes reported that she had suicidal ideation, but did not act out on it because she was on this 24-hour hospital unit, and she reported guilt, shame, depressed mood, and anger. Notes reported that she continued to struggle with low mood and maladaptive coping strategies and there was concern for her safety if not in this setting and if she went home prematurely. Notes reported that she still had suicidal ideation. After observing her 2 more days without reports of suicidal ideation, plan, or intent, or severe depressive symptoms, the chart notes no longer provided enough specific evidence to support that she still required 24-hour hospital treatment after that. Notes reported euthymic mood, no safety concerns, and she denied suicidal or homicidal ideation. Notes reported euthymic mood, and she denied suicidal or homicidal ideation or self-injurious behavior. Notes reported that she was discharged.

As a result, modify the previous decision and approve coverage for continued inpatient mental health treatment in this hospital for specified dates but deny coverage for continued inpatient mental health treatment in this hospital beyond those dates. The insurer acted reasonably, with sound medical judgment, and in the best interests of the patient for part of the stay but not the rest.

Based on the above, the medical necessity for the inpatient mental health stay is partially overturned.