Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Self-mutilatory behavior

Treatment:  Inpatient admission  

The insurer denied coverage for inpatient admission.  The denial was modified.

This patient is a female who was admitted to inpatient mental health treatment in this hospital due to self mutilatory behavior by cutting herself with a knife, depressed mood, crying, agitation, and she reported stressors.  She reportedly had a history of opiate use and was on Methadone maintenance in addition to taking Haldol, Venlafaxine, Klonopin, and Lorazepam.  She reportedly was homeless.  She had past reported suicide attempts, self-injurious behavior, and past psychiatric hospitalizations.  She also was in the Personalized Recovery Orientation Service (PROS) program.  The patient was discharged.

The insurer denied coverage for inpatient mental health treatment in this hospital as not medically necessary treatment.  This reviewer disagrees with the decision to deny coverage for inpatient mental health treatment in this hospital for a specified range but agree with the decision to deny coverage for other days specified as the chart notes supported that she was considered a danger to self by cutting self with her past history of suicide attempts, current depressed mood and crying and stressors, and her past history of opiate use.

The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Suicidal Behaviors reports that patients with past suicide attempts are at high risk for suicide and that past suicide attempts are the single most reliable predictor of suicide.  It also states that patients with major depressive episodes and a history of substance use are at increased risk for suicide.  This patient had worsened depressive symptoms and stressors and cut herself with a knife, so she was a danger to self.  Even though she reported that this was not a suicide attempt, it is appropriate and standard care to assess a patient with past suicide attempts and current self-injurious behavior and depressive symptoms with a history of substance use who is homeless and has current stressors for a few days even when they deny suicidality, as they are still considered at risk for suicide.  

The APA Practice Guidelines for the Treatment of Patients with Suicidal Behaviors report also 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 and 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 for a few days until a specified range.  However, as of a date indicated there were no reports of further suicidal ideation, plan, or intent, or self-injurious behavior, severe depressive symptoms, withdrawal symptoms, severe agitation, aggression, psychotic symptoms, or acute medical instability. 
 
As a result, modify the insurer's decision and approve continued inpatient mental health treatment in this hospital from a specified range but deny continued inpatient mental health treatment in this hospital for a specified couple of days.  It appeared that the insurer acted reasonably and in the best interests of the patient from a specified range but not for a specified couple of days.