Psychiatric Disorders: A Case Study
The records have been reviewed. The subject member is an adolescent male born 07/24/2002, who has been diagnosed with Major Depressive Disorder, generalized anxiety, panic disorder, social phobia, social anxiety, anorexia, self-injurious behavior. His treating provider, Ricardo P. Bayola, MD recommended that he be placed in continued adolescent inpatient psychiatric care from 02/11/2016 forward.
The carrier has denied coverage of continued adolescent inpatient psychiatric care as not medically necessary. A letter from the carrier to the member, dated 05/24/2016, states in part:
“Deny 2/11 and days forward as the documentation submitted to the Plan and reviewed at the time of the determination does not fulfill InterQual criteria under "Symptoms/Behavior" …show more content…
He was admitted for inpatient psychiatric treatment at the Sacred Heart Eau Claire facility under a Chapter 51 Safety Order on 02/08/2016 after admitting the desire to harm himself while at school. He has a history of depression and according to the documentation submitted, has been seeing a counselor every other week for his depression and anxiety. His counselor has been aware of his frequent suicidal feelings, and has put him on a safety plan. The documentation reflects that a "suicide watch" has been in place for approximately two years.
The member has a history of self-harm in the form of “cutting” behavior. His “cutting” history includes cutting approximately every other month on his arms; the most recent incident occurred approximately three weeks prior to his admission. During his initial presentation physical and history, he reported having the desire to kill himself on a daily basis. He acknowledged seeing a counselor, but said that he did not trust her. He periodically refuses to eat. While at home, he gets angry with his mother, throws things, and flips furniture. The member acknowledged having symptoms of anxiety, stress, and panic attacks. His initial presenting diagnosis at the Sacred Heart Facility was major depressive disorder, generalized anxiety disorder, panic disorder, social phobia, and social anxiety disorder. He is taking Prozac, which is his only outpatient psychotropic …show more content…
The court found probably cause for continued care. As result, the member returned to the Sacred Heart Eau Claire facility where he remained in inpatient psychiatric care through his date of discharge on 02/19/2016. The member was discharged to home with recommendations for continued psychiatric follow up, therapy, intensive in-home family therapy, and family respite services.
The member's health plan reviewed his presenting clinical findings and determined that the medical records did not provide sufficient evidence of clinical symptoms to support continued inpatient psychiatric care from 02/11/2016 through 02/19/2016. The denial of coverage for these dates has been appealed by the member's family and treating facility, and is the focus of this review.
The medically accepted standard of care is to treat patients in the least restrictive environment medically necessary based on their presenting clinical
The carrier has denied coverage of continued adolescent inpatient psychiatric care as not medically necessary. A letter from the carrier to the member, dated 05/24/2016, states in part:
“Deny 2/11 and days forward as the documentation submitted to the Plan and reviewed at the time of the determination does not fulfill InterQual criteria under "Symptoms/Behavior" …show more content…
He was admitted for inpatient psychiatric treatment at the Sacred Heart Eau Claire facility under a Chapter 51 Safety Order on 02/08/2016 after admitting the desire to harm himself while at school. He has a history of depression and according to the documentation submitted, has been seeing a counselor every other week for his depression and anxiety. His counselor has been aware of his frequent suicidal feelings, and has put him on a safety plan. The documentation reflects that a "suicide watch" has been in place for approximately two years.
The member has a history of self-harm in the form of “cutting” behavior. His “cutting” history includes cutting approximately every other month on his arms; the most recent incident occurred approximately three weeks prior to his admission. During his initial presentation physical and history, he reported having the desire to kill himself on a daily basis. He acknowledged seeing a counselor, but said that he did not trust her. He periodically refuses to eat. While at home, he gets angry with his mother, throws things, and flips furniture. The member acknowledged having symptoms of anxiety, stress, and panic attacks. His initial presenting diagnosis at the Sacred Heart Facility was major depressive disorder, generalized anxiety disorder, panic disorder, social phobia, and social anxiety disorder. He is taking Prozac, which is his only outpatient psychotropic …show more content…
The court found probably cause for continued care. As result, the member returned to the Sacred Heart Eau Claire facility where he remained in inpatient psychiatric care through his date of discharge on 02/19/2016. The member was discharged to home with recommendations for continued psychiatric follow up, therapy, intensive in-home family therapy, and family respite services.
The member's health plan reviewed his presenting clinical findings and determined that the medical records did not provide sufficient evidence of clinical symptoms to support continued inpatient psychiatric care from 02/11/2016 through 02/19/2016. The denial of coverage for these dates has been appealed by the member's family and treating facility, and is the focus of this review.
The medically accepted standard of care is to treat patients in the least restrictive environment medically necessary based on their presenting clinical