Acute Inpatient Psychiatric Hospitalization denials: what the review data shows

Where the denial was overturned

The patient is a 16-year-old female who had been in treatment with mental health provider’s within the Health Plan prior to her admission to the non-Plan acute inpatient psychiatric facility for comprehensive evaluation. The evaluation was prompted by the patient stealing money from her aunt and also having a disassociative/transient psychotic episode. The patient also had recently disclosed that she was sexually molested when on visitation with her father by a perpetrator with whom she was left alone. The patient lives with her biological mother and step-father. There continues to be some interaction and visitation with the biological father.

A 52-year-old female enrollee requested acute inpatient psychiatric services for medical treatment of her behavioral health condition. Findings: The physician reviewer found that the patient was plagued with a debilitating unilateral affective disorder and a co-occurring chronic anxiety disorder. The patient had an exacerbation of her mental illness that compromised her baseline functionality. Although future oriented and not acutely suicidal, her thoughts of death and largely neurovegetative symptom complex that generated prompt consideration of electroconvulsive therapy as a primary therapy warranted hospitalization initially. However, the record does not support treatment at the acute inpatient level of care shortly thereafter. The nursing staff completed a suicide risk assessment during intake and the patient denied suicidal ideation.

Where the denial was upheld

The patient is a 36-year-old male with a prior history of bipolar disorder. He was admitted to inpatient treatment on 1/18/05 due to decreasing appetite with a 10-pound weight loss, increased irritability, weakness, headaches, and a great deal of oversleeping. The patient estimated the latter at 21 hours a day for about three weeks. Previously, he had been treated with Adderall, which was stopped three weeks prior. More recently he was treated with Lexapro, Trileptal, and Provigil. As of his growing more depressed and irritable, he stopped the Trileptal, but did not notice any difference in his state. Upon admission, he actually denied feeling depressed per se, but did present with the aforementioned history of neurovegetataive change.On 1/19/05, the patient later indicated he was feeling down, sad and guilty that he was unable to work and earn more money.

A 66-year-old female enrollee has requested emergent psychiatric care followed by acute inpatient level of care for treatment of her medical condition. Findings: The physician reviewer found that the services rendered during the initial treatment period were not required at the emergent level of care and the services rendered during the second treatment period were not medically necessary at the acute inpatient level of care. American Psychiatric Association (APA) practice guidelines indicate that patients should be managed in the least restrictive setting that is likely to be safe and effective. Based on the documentation provided, the patient’s condition had stabilized by initial treatment date and she was no longer experiencing a psychiatric emergency.

These are outcomes from California’s external review program — an independent physician panel that binds the insurer. Every state has an equivalent process, and internal appeals succeed even more often. Cite the outcome record for Acute Inpatient Psychiatric Hospitalizationwhen you appeal: reviewers routinely find that denials like yours didn’t hold up.