Diagnosis: Schizophrenia

Treatment: 46 units of Inpatient Mental Health Treatment

The insurer denied the 46 units of Inpatient Mental Health Treatment. The denial was reversed.

This is a male patient who was brought to the Emergency Department (ED) by emergency medical service (EMS) with psychotic episodes. The patient had a history of multiple psychiatric hospitalizations for schizophrenia. He was evaluated by psychiatry. He was noted to be paranoid, hostile, agitated and was talking to himself. He denied suicidal and homicidal ideations. It was reported by his mother that the patient's behavior was erratic and that he had not taken his medication in a year. During his admission the patient continued to experience psychotic symptoms such as suspiciousness, anxiety, irritability, and anger. The patient was treated with Clozapine and Haloperidol decanoate. Due to the patient's increasing delusional symptoms throughout his six week hospital stay, his medications were increased accordingly. It was noted that the patient did have a positive respond to the treatment plan. The patient was discharged to a long term care inpatient facility because he could not be safely discharged to the community.

Based upon the information available the patient medically required continued acute inpatient psychiatric treatment. The patient continued to display severe and acute symptoms of schizophrenia, including acute psychosis and disorganized behavior, despite appropriate and ongoing psychiatric treatment. There were no safe alternative settings for the patient other than a long-term inpatient hospital setting. The appropriate setting could not be utilized until the day of his discharge.

This finding is consistent with the general standards of psychiatric care and the American Psychiatric Association (APA) Guidelines for the Treatment of Patients with Schizophrenia.

The carrier's denial of continuation of coverage for 46 units of Inpatient Mental Health Treatment is reversed. The medical necessity is substantiated.