Diagnosis: Mood Disorder
Treatment: Inpatient Psychiatric Admission

The insurer denied inpatient psychiatric admission. The denial was modified.

This is a male patient was admitted to the hospital for inpatient mental health treatment due to severe behavioral symptoms. These behaviors included aggressiveness, poor impulse control, severe agitation, restlessness, extreme anger, and medication noncompliance. He reported that he lived with his parents and he smoked 6-8 joints of cannabis per day; he had positive toxicology for cannabis. He had a past psychiatric history of Mood Disorder with past hospitalizations. It was reported that he had taken Zoloft and Risperidone. He was discharged home after a period of medical stability.

The MCG Behavioral Health Inpatient Level of Care Adult criteria report that in order to meet criteria for inpatient behavioral level of care, a patient needs to present as an imminent danger to self, imminent danger to others, have severe psychiatric or behavioral symptoms, have severely dysfunctional living including inability to care for self, have an unwillingness to participate voluntarily, or a less restrictive level of care is not feasible. InterQual Behavioral Health Adult Psychiatry inpatient medical necessity criteria reports that criteria for inpatient treatment is met if one has any of the following: assaultive behavior within 24 hours, catatonia, command hallucinations to harm self or others, destruction of property with poor impulse control within 24 hours, disorganized behavior, unstable eating disorder, fire setting, homicidal or suicidal attempt within 24 hours, suicidal or homicidal ideation with high risk for an attempt, mania, risk of harm to self or others, non-suicidal self-injury and continued danger to self, positive psychotic symptoms with risk of harm to self or others, post-traumatic stress disorder (PTSD) with risk of harm to self or others, psychomotor agitation and potential for violence, severe social withdrawal and refusing treatment, unavailable support or inability to provide needed care and supervision and there is acute deterioration in functioning. This patient had severe psychiatric and behavioral symptoms requiring 24-hour hospital treatment including aggressive behavior and property destruction.

As a result, modify the previous decision and approve coverage for inpatient mental health treatment in this hospital the initial day of admission, but deny coverage for inpatient mental health treatment in this hospital for the following two. The insurer acted reasonably and with sound medical judgment and in the best interests of the patient for the last two days of admission, but not on first one.

The carrier's denial of coverage for the inpatient psychiatric admission from is modified.