Diagnosis: new-onset psychotic symptoms and chronic headache, history of major depressive disorder
Treatment: Continued Inpatient Admission
The insurer denied the Continued Inpatient Admission.
The denial is upheld.

This was the first psychiatric admission for this patient with a history of major depressive disorder who was referred for admission due to new-onset psychotic symptoms and chronic headache. She had initially been evaluated in the emergency department and discharged home. For the previous two or three months the patient complained of worsening fatigue, dizziness, headaches, memory problems and "no longer being allowed to take care of the kids." She complained of trouble concentrating and remembering things. She admitted that she at times forgot if she took her medications or that she left the stove on. She spent most of her time sitting in a chair or in her room.

The patient had multiple psychosocial stressors including financial problems, joblessness, and the responsibility of caring for her husband who had a history of strokes. She had difficulty sleeping and reported being able to sleep only three or four hours a night. She reported nightmares of choking and of snakes trying to catch her. She was alert and oriented, but when asked if she could name the current president, she asked the psychiatrist if she passed her citizenship test. She denied suicidal intent but admitted to passive suicidal ideation. She did however admit to auditory hallucinations with multiple voices calling her nicknames and telling her to hit herself. Her outpatient psychiatrist told her to discontinue her medications the day before admission. They had included Lexapro 10 milligrams (MG) daily, omeprazole 40MG daily, sumatriptan 50MG as needed, and topiramate 25MG twice daily.

The patient was provided reassurance, support and pharmacotherapy. Over the course of her stay she showed improvement in mood and anxiety. A psychiatry progress note reported that the patient was cooperative and appropriate. There was no further evidence of psychotic symptoms such as hallucinations or delusions. Her mood remained depressed and her affect was constricted.

No, the proposed continued inpatient admission was not medically necessary.

The patient's mood had improved significantly. She described her mood as being good and staff described her affect as bright. There was never any question of suicidal plan or intent or behavioral dyscontrol. She had no further psychotic symptoms. She tolerated her medications without difficulties. Nothing in the documentation reviewed indicates that treatment could not have continued equally safely and effectively in a less restrictive setting.