Diagnosis: of Major Depressive Disorder.

Treatment: Inpatient Mental Health Treatment, revenue code 0124.

The insurer denied the Inpatient Mental Health Treatment, revenue code 0124.

The denial was upheld.

This is female who was admitted for inpatient mental health treatment due to worsened depressive symptoms including suicidal plan to overdose with medication, depressed mood, crying, and self-injurious behavior as she was biting her arms, and experiencing agitation, poor sleep and appetite. The patient had a reported diagnosis of Major Depressive Disorder (MDD). The patient had four past reported psychiatric hospitalizations. The patient was admitted and required a series of electroconvulsive therapy (ECT) treatments and medications that included lithium, olanzapine, venlafaxine, clonazepam, and gabapentin. The patient was stabilized and discharged with a referral to partial hospitalization program (PHP).

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, severe depressive symptoms, or inability to adequately care for basic needs are candidates for hospitalization. In this case this patient had no reports of suicidal ideation, plan, or intent, severe depressive symptoms, inability to care for basic needs, aggressive or self-injurious behavior, psychotic symptoms, substance use problems or substance withdrawal, or acute medical instability. Notes reported significant improvement in patient's mood with denial of suicidal/homicidal ideation, plan, or intent and hallucinations. The noted indicated that the patient was in no apparent distress, had no acute issues, and was compliant to treatment with good sleep and appetite. Notes dated a few days later reported that the patient had no heightened anxiety or ruminating thoughts, and did report severe depressive symptoms. There was no documentation at that time that this patient had severe depressive symptoms or suicidal thoughts.

Based on the review of the medical record the chart notes did not provide enough clinical evidence to support that this patient was an imminent danger to self or others, or unable to adequately care for her basic needs. 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.

The health plan acted reasonably with sound medical judgment, and in the best interests of the patient.

Based on the above, the medical necessity for continued Inpatient Mental Health Treatment, revenue code 0124 is not substantiated. The insurer's denial should be upheld.