Diagnosis: Psychosis

Treatment: Inpatient mental health treatment, medication, monitoring

The insurer denied the continued inpatient mental health treatment. The denial was reversed.

This patient is male who was admitted to inpatient mental health treatment due to psychotic symptoms. He was experiencing persecutory and paranoid delusions, disorganized thinking, and poor reality testing, insight, and judgment, medication noncompliance including refusal to take medications, withdrawn, irritable and angry mood, and bizarre behavior. He had past psychiatric hospitalizations. He eloped from the facility during triage process. He was prescribed the medication Abilify, but he stated that he did not want to take the medication. He refused to sign consent to talk to a friend to arrange for discharge. He had a court hearing, and it was determined that he should remain inpatient for 5 additional days to try to arrange for discharge.

The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Schizophrenia indicates that patients are candidates for inpatient level of care when experiencing one of the following symptoms: 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. This patient still had psychotic symptoms during the denial period, including persecutory and paranoid delusional thinking, disorganized thinking, poor reality testing, insight and judgment, thought blocking, refusal to sign consent for discharge planning and also refusal of medication, impoverished speech, bizarre behavior, and psychomotor retardation. It was reported that he could not care for himself due to psychotic symptoms. He continued to require 24-hour hospital treatment until discharge.

Based on the above, the medical necessity for the continued inpatient mental health treatment services is substantiated. The insurer's denial is reversed.