The patient has a diagnosis of Major Depressive Disorder (MDD) and Anxiety. Case notes document that the patient has had no prior inpatient hospitalizations. The patient developed severe depressive symptoms with a suicidal plan to overdose and was prevented from overdose by family members who then referred the patient to the emergency department for evaluation. In the emergency room the patient was evaluated and her mental status examination noted severe depressive symptoms with suicidal ideation, anxiety, agitation, lack of will to live, hopelessness and helplessness. In addition to diagnoses of MDD and anxiety, the patient had significant medical symptoms including diabetes mellitus (DM), thrombocytopenic purpura, and morbid obesity with a body mass index (BMI) of 44.9. The patient was also documented to be a daily smoker. The patient had diminished social support due to being homeless. The treatment included individual and group therapy, and a combination of psychotropic medications including venlafaxine, aripiprazole, as well as benztropine as needed (prn) and lorazepam prn, and later Buspar. The patient initially required each (q) 15-minute checks for safety. Medical consultation was provided for her serious medical diagnoses.

The health plan's determination is overturned. the Inpatient Psychiatric Admission was medically necessary for this patient. The DOS through discharge were medically necessary for several reasons. This patient was globally distressed psychiatrically and medically. The patient suffered severe depressive symptoms that had not substantially abated and if discharged on that date would have a high probability of requiring readmission or would have an increased vulnerability to self-harm. The accompanying co-morbid anxiety worsened her depressive symptoms. The homelessness indicated a reduced support system. The case notes documented that the patient was still dysphoric, agitated at times, with intermittent anxiety. While the pateint was mildly improved from admission, she was not ready for discharge using good medical judgment. The patient's mental status still showed depression, anxiety, hopelessness, and a labile mood.The Buspar was increased to treat anxiety. The patient showed substantial improvement for the first time. The patient was cooperative, less anxious, less depressed, with organized thinking, and without suicidal ideation, as well as improved in insight and judgment. The patient could therefore be discharged with good medical judgment, in accord with current standards of best care, and in accord with the medical literature.