Diagnosis: Schizophrenia

Treatment: Continued behavioral health inpatient hospital admission

The insurer denied coverage for the continued behavioral health inpatient hospital admission.

The denial is upheld.

This is a female patient who was admitted for inpatient mental health treatment after being brought in by the police after her mother called 911 due to the patient's physical aggression towards her and threatening behavior. The patient was noted to be responding to internal stimuli, talking to self, was loud and verbally abusive, had noncompliance with medications, had pressured speech, erratic behavior, bizarre behavior including laughing and clapping, slamming doors, agitation, and she stopped eating and sleeping. The patient was also smoking cannabis. The patient's psychiatric diagnoses included Schizophrenia and Cannabis Use Disorder. The patient's inpatient treatment included intramuscular (IM) Haldol, Ativan and Benadryl, and oral Lithium. The patient clinically improved and was discharged on day 15 of admission.

The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Schizophrenia reports that patients with hallucinations, delusional thinking, disorganized behavior, suicidal or homicidal plan or intent, agitation, or aggressive behavior are candidates for inpatient treatment. In this case, as of day 12 of admission, there were no reports of further serious psychotic symptoms such as delusions, hallucinations, or disorganized behavior, suicidal or homicidal ideation, intent, or plan, manic symptoms, aggressive, threatening, self-injurious, or agitated behavior, withdrawal symptoms or acute medical instability. Notes on day 12 of admission reported that the patient had no agitation, was socially interactive with peers, had no suicidal or homicidal ideation or hallucinations, and that the patient had good mood with appropriate affect, appropriate hygiene, and adequate behavioral control. Notes on day 13 to day 14 of admission reported that the patient denied hallucinations, suicidal or homicidal ideation, and she was calm and in good control. The patient was discharged on day 15 of admission.

Based on the review of the medical record, as of as of day 12 of admission, there were no reports of acute or severe mental health or behavioral symptoms that justified this patient's need for 24-hour acute hospital treatment and 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 treatment setting as of then or that could not be achieved in a less restrictive level of care as of then. Thus, continued inpatient psychiatric treatment in this hospital from day 12 to day 15 of admission was not medically necessary for this patient.

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

The carrier's denial of coverage for the continued behavioral health inpatient hospital admission should be upheld. The medical necessity is not substantiated.