201907-119687
2019
Fidelis Care New York
Medicaid
Mental Health
Mental Health: Inpatient
Medical necessity
Overturned
Case Summary
The patient is a single female with a diagnosis of major depressive disorder, recurrent, severe, without psychosis (MDDR), and generalized anxiety disorder (GAD) with panic disorder (PD). Records document that for about two or more weeks prior to admission the patient was decompensating with worsening depressive symptoms. She experienced suicidal ideation with a plan to hang herself. Her depressive symptoms worsened to the point of functional impairment: she was not able to work, often calling in sick. Her symptoms included increased crying, anxiety, panic with shortness of breath, helplessness, hopelessness, decreased concentration and insomnia. She lost 20 lbs. She has a positive family history for substance use disorder. She was being cared for by an outpatient provider for six years and was taking her medications but had not experienced improvement despite a long list of medications tried, including Prozac, Abilify, Latuda, Paxil, Wellbutrin, Lexapro, Celexa, Effexor, Zoloft, and Cymbalta which were all found to be ineffective. She has a long history of substance use, and at the time of this admission, was on Suboxone for opiate use disorder (OUD). In the past she suffered from alcohol use disorder and cannabis use disorder. She is more vulnerable because of a history of two rapes. In the past she required two prior psychiatric admissions for her depressive disorder. Her inpatient hospital treatment included medication , supportive therapy, and an urgent assessment for electroconvulsive therapy (ECT) which was deemed of probable help and scheduled to be received on an outpatient basis. Her inpatient medications included Suboxone, Lexapro, trazodone, and Wellbutrin.
The health plan's determination is overturned.
Yes, the requested health treatment of inpatient psychiatric hospital admission was medically necessary for this patient based on the information and reasoning above. This admission reflects good clinical judgment and is in accord with current standards of best treatment, and with the medical literature.
This patient was rapidly decompensating in her depressive and anxiety symptoms with substantial functional impairment and little social support. She has a chronic and severe illness. She had a specific suicide plan shortly before admission. She required two past hospitalizations. She is in recovery from opiate use disorder and is on Suboxone; vulnerable to return to use of opiates, alcohol, or cannabis to improve her mood and her pain. This is especially true in view of her lack of effective response to multiple medication trials. Of special import for understanding the severity of her MDDR is her 20 lb. weight loss and vegetative symptoms noted by the ECT consultant. The consultant also noted possible mixed bipolar features, often difficult to diagnose and treat. Asberg in her studies of MDD has found that substantial weight loss is a sign of serious depressive illnesses. This hospitalization was brief and strategic and served its purpose. Trying to treat this patient on an outpatient basis had a significant possibility of morbidity or mortality for outcome.