Diagnosis: Suicidal ideation and plan

Treatment: Inpatient mental health treatment

The insurer denied coverage for inpatient mental health treatment. The denial was upheld.

This patient is a female who was admitted to inpatient mental health treatment due to suicidal ideation and plan, inability to contract for safety, anxiety, panic attacks, and depressive symptoms. It was reported that she had a diagnosis of Major Depressive Disorder, Binge Eating Disorder, and rule out Borderline Personality Disorder. She reportedly had Lamictal and Vyvanse discontinued and was started on Abilify. This was her first reported hospitalization and episode of suicidal thoughts. She reportedly had Dialectical Behavioral Therapy (DBT) treatment also. She reportedly improved and was discharged.

The insurer denied coverage for continued inpatient mental health treatment in this hospital as not medically necessary treatment then.

This reviewer agrees with the decision to deny coverage for continued inpatient mental health treatment in this hospital as the medical records did not provide enough specific evidence to support that she only required this acute psychiatric hospital level of care then or that she could not be safely and effectively treated in a less restrictive level of care by then.

The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Major Depressive Disorders reports that the least restrictive level of care for safe and effective treatment is appropriate and that patients with suicidal plan or intent or behaviors, or inability to adequately care for basic needs are candidates for hospitalization. She reportedly had suicidal thoughts and plan on admission as well as significant depressive symptoms and required and received 24 hour acute psychiatric hospital treatment at that time. However, the medical records by a specified date did not report further suicidal ideation, intent, plan, or behavior. There were no reports as of that specified date of severe depression, feelings of hopelessness, severe psychomotor retardation, inability to adequately care for basic needs, and there were no reports of self-injurious behavior. Also, as of then 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.

Inpatient mental health treatment at this hospital was not medically necessary. It appeared that the health care plan acted reasonably and with sound medical judgment and in the best interest of the patient.

The carrier's denial of coverage for the inpatient admission upheld. The medical necessity is not substantiated.