Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Psychotic symptoms

Treatment: Inpatient mental health treatment 

The insurer denied coverage for inpatient mental health treatment. The denial was modified.

This patient is a male who was admitted to this inpatient mental health treatment due to psychotic symptoms including command auditory hallucinations suicidal in nature telling him to kill himself and stab himself. He reportedly had past suicide attempts, substance use history including cocaine and cannabis, past legal issues, past aggression/violence, and he was non-compliant with medications. He reportedly had past psychiatric hospitalizations. He had a diagnosis of Schizoaffective Disorder. He took Risperidone, Lithium, and Clozapine. 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 improved and did not require 24 hour hospital treatment then, and 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 for certain days but agrees with the decision to deny coverage for continued inpatient mental health treatment in this hospital for other specified days thereafter. 

The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Schizophrenia reports that patients with hallucinations, delusional thinking, disorganized thinking or behavior, suicidal or homicidal plan or intent, agitation, or aggressive behavior, or inability to adequately care for basic needs are candidates for hospitalization. In this case this patient still had psychotic symptoms until a specific date as it was reported that he was febrile and started antibiotics and then his psychotrophic medication was stopped for 24 hours and he had reports of command auditory hallucinations telling him to bang his head. He required Haldol and Ativan IM and was on 1:1 observation. After one day of observation without further reported psychotic symptoms the day after the specified date referenced above, there was no further reported evidence that he had psychotic symptoms or required further acute psychiatric hospital treatment. It was appropriate to observe him for one day without reported symptoms in this hospital setting due to his recent serious psychotic symptoms of command auditory hallucinations to hurt self.

As of a certain date there were no further reports of significant psychotic symptoms, severe depressive symptoms, homicidal or suicidal ideation, plan or intent, and 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 recommendation is to modify the previous decision and approve coverage for continued inpatient mental health treatment in this hospital for a few days but deny coverage for continued inpatient mental health treatment in this hospital thereafter.

Based on the above, the insurer's denial is modified. The inpatient behavioral health hospital admission for a few days was medically necessary. It was not medically necessary thereafter.