Diagnosis: acute depression; bizarre delusions

Treatment: inpatient behavioral health treatment

The insurer denied coverage for 7 days. The denial was modified.

This patient is a female admitted for acute inpatient psychiatric treatment. She was diagnosed with Schizoaffective Disorder, Bipolar; Rule Out Major Depressive Disorder with Psychosis; Rule out immunodeficiency Induced Psychosis. She was discharged with the diagnosis of Schizoaffective Disorder, Bipolar Type.

The insurer has denied coverage for inpatient behavioral health treatment.

The medical record indicates the patient had been residing in a nursing home facility and was experiencing the following symptoms; acute depression with crying spells, thoughts of harming herself, paranoid and bizarre delusions, internal stimulation, and odd mood and behavior. She was prescribed the following medications: Risperdal 4 mg daily and Prozac 20 mg daily at the time of admission. She had a history of extensive mental illness. She had a history of multiple psychiatric hospitalizations and multiple medication trials. She was single, unemployed and undomiciled. She had poor impulse control. She had thought disorganization. She was treated with Invega Sustenna and Risperdal.

Based upon the information available this patient required acute inpatient psychiatric treatment; the insurer's denial is reversed for a specified date range of time. She had ongoing severe psychosis through the first 3 days. The level of this psychosis could not be safely or effectively treated outside of an acute inpatient setting. The acute inpatient hospital treatment on these dates is consistent with the general standards of medical/psychiatric care, APA Guidelines for the Treatment of Schizophrenia, and InterQual Behavioral Health Criteria 2018 Adult and Geriatric Psychiatry, Hospitalization, Psychiatric, Adult, Mental Health Criteria.

There is no medical documentation indicating the need for acute inpatient psychiatric treatment for the last 4 days; the insurer's denial for these days is therefore upheld. This finding is consistent with the general standards of psychiatric care and the APA Guidelines for the Treatment of Patients with Schizophrenia.

The health plan did not act reasonably with respect to the denial of inpatient treatment for one of the specified date ranges.

Based on the above, the medical necessity for the behavioral health inpatient treatment for a specified range is partially substantiated. The insurer's denial is modified. Approve one date range and deny the other date range.