Diagnosis: Depression.
Treatment Inpatient mental health.
The insurer denied the inpatient mental health stay. The health plan's determination is overturned in part. 14 additional days are medically necessary.

This case involves an adult male who called 911 and was brought by emergency services to the emergency department and admitted for acute inpatient psychiatric treatment. The patient had become increasingly depressed with suicidal ideation, and deterioration in functioning culminating in his presentation to the emergency department and admission after medical screening. He had a history of mood disorder best characterized as bipolar mood disorder with severe depressive episodes and psychiatric treatment with therapy and medications. He had co-occurring substance use disorders including opioid use disorder in treatment with methadone maintenance, and use of cannabis and benzodiazepines.

14 additional days are medically necessary. The patient's presentation and clinical features included severe symptoms of mood disorder, suicidal risk, and deterioration in functioning in the context of substance use disorder. The patient remained at risk for relapse and suicidal behavior during the time interval under review to day 14 when he no longer represented a safety concern and was functioning better with improved symptoms and medication adherence. Additionally, a safe and clinically appropriate discharge plan and disposition was critical in this case to prevent re-hospitalization or immediate relapse. The patient could not have been expected to participate in treatment at a lower level of care in this case scenario until he had stabilized. In this regard, the patient no longer warranted continued acute inpatient level services from day 14 forward.