top of page
< Back

202003-126481

2020

Wellcare of NY

Medicaid

Mental Health

Mental Health: Inpatient

Medical necessity

Overturned

Case Summary

Diagnosis: Schizophrenia
Treatment: Inpatient mental health admission

The insurer denied coverage for continued inpatient mental health admission. The denial is reversed.

This was then a female who was admitted to the inpatient mental health treatment due to suicidal ideation and plans to jump out of a train or take pills, paranoid delusions, disorganized and illogical thinking, poor insight, substance use, and self-harm. The patient had a diagnosis of schizophrenia. The patient's history was significant for multiple past psychiatric hospitalizations. The patient took Risperidone and Trazodone.

The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Schizophrenia reports that patients with 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 are candidates for hospitalization.

In this case, this patient continued to have exhibit psychotic symptoms, including disorganized and paranoid thinking. Notes reported that the patient had disorganized thoughts, thought blocking, circumstantial thinking, and internal preoccupation. Notes reported that the patient was oddly related, guarded, delusional, and had illogical thoughts, internal preoccupation, and had impaired insight. Notes reported that the patient had disorganized and paranoid thinking. Based on this review of the medical chart, this patient was noted to have psychotic symptoms, and was at high risk for self harm given that this patient had thought of suicidal ideations and plans on admission. The patient's history of multiple past psychiatric hospitalizations in the past as well as this persistent psychotic symptoms status post trauma put this patient at high risk for self-harm if discharged prematurely from inpatient level of care and monitoring. It was not until the date of this patient's discharge, that this patient had no reported overt delusions or disorganization. Thus, continued inpatient mental health admission was medical necessary for this patient's care.

The health plan did not act reasonably with sound medical judgment, and in the best interest of the patient.

The carrier's denial of coverage for the continued inpatient mental health admission should be reversed. The medical necessity is substantiated.

bottom of page