Diagnosis: Major Depressive Disorder

Treatment: Inpatient mental health admission, medication, monitoring

The insurer denied the inpatient mental health admission. The denial was upheld.

This male was admitted to inpatient mental health treatment due to depressive symptoms including depressed mood, feelings of hopelessness, helplessness, guilt, worthlessness, decreased energy, repeating the same words, feeling stressed, withdrawn, having difficulty concentrating, and anxiety. He reported feeling pressure in his head. He scratched his arms 3 weeks prior to admission to relieve anxiety. He had no reported suicidal ideation, plan, intent, or behavior, or past suicide attempts. He felt responsible for his son's depression. He had a diagnosis of Major Depressive Disorder.

The medical records provided did not provide enough specific evidence to support that he required only 24 hour acute psychiatric hospitalization or that he could not have been treated effectively in a less restrictive level of care. The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Major Depressive Disorder reports that the least restrictive level of care for safe and effective treatment is appropriate. It also states that patients with suicidal intent or plan, or behaviors, or who present as an imminent danger to self or others are in need of hospital treatment. This patient did not have reports of suicidal ideation, plan, intent, behaviors, or past suicide attempts. There was no reported evidence that he was considered an imminent danger to self or others.

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. There were no reports of hallucinations, delusional thinking, manic episodes, or acute medical instability.

Based on the above, the medical necessity for the inpatient behavioral health admission is not substantiated. The insurer's denial is upheld.