Diagnosis: Substance abuse and mental illness
Treatment: Inpatient admission
The inpatient admission was medically necessary.
The patient represented an acutely elevated risk of dangerous behaviors and there was no less-restrictive treatment environment appropriate. The acute risk factors of depression, pain, and recent substance abuse with the chronic risk factors of potentially dangerous behaviors suggest that the patient would have been at an acute risk of self-injurious behaviors (including but not limited to suicide) were he to have been discharged from the inpatient hospital setting. The patient was discharged from the inpatient psychiatric hospital setting as soon as a less-restrictive treatment setting was appropriate.
The patient represented an elevated risk of dangerous behaviors including self-injury and suicide, and there was no less-restrictive treatment environment appropriate. Therefore the treatment was medically necessary. While the patient was not endorsing active suicidality or homicidality, the patient remained depressed and there were ongoing medication changes. The patient had multiple static risk factors for potentially dangerous behaviors including prior suicide attempts, medical illness, chronic pain, and diagnosis with a severe mental illness. Therefore the patient represented a chronic risk of potentially dangerous behaviors. The fact that patient remained depressed and with ongoing medication changes were acute risk factors for dangerous behaviors. Furthermore, the fact that there was no less-restrictive environment of care appropriate suggests that ongoing inpatient psychiatric hospitalization was medically necessary and should be covered by the patient's health plan.