Appeal type: Medical necessity
Decision: Upheld

The patient is a female with a mood disorder best characterized as bipolar II disorder with co-morbid social anxiety and panic disorder and a personality disorder with narcissistic, borderline and avoidant traits.  She had worsening symptoms of anxiety and depression and a decline in functioning that resulted in a referral to residential mental health treatment.  She had failed achieve a remission from outpatient mental health treatment that had included medications and therapy, and he had relationship problems and the tendency to isolate socially that contributed to her mood disturbance.  Moreover, there was a history of persistent depression and suicidal ideation in the context of family problems that had occurred from the time of early adolescence.

The patient was admitted to residential level treatment with a comprehensive evaluation, and with development of a treatment plan.  She was treated with medication with clinically appropriate adjustments, and she engaged in individual, group, and milieu therapies with significant support from her family with family focused sessions.  The patient made gradual progress with her therapy including improvement with social interactions and better coping.  Medications had been resumed and/or adjusted to include lamotrigine, lithium, Viibryd, and vitamin supplements, as well as decreasing dosages of quetiapine and use of Belsomra for persistent insomnia.

By the first date under review, the patient was noted to be in a better place emotionally and was participating actively in her treatments with step down to Group Residential level care.  She was receiving four times weekly individual therapy together with group sessions and other therapeutic activities to address her interpersonal functioning.  She had no further evidence of active suicidal plan or intent with persistent suicidal ideation that had been present since age 13 years.  Going forward she was noted to display improved mood and diminished anxiety.  She continued to receive evidence-based therapies with work on coping skills and other therapies to address persistent self-loathing and shame, and problems within the family constellation.

Again, treatment plan going forward to discharge included individual and group therapy sessions including medication management with ongoing psychiatric evaluations.  Additionally, the patient continued to utilize her skills from past cognitive behavioral and dialectical behavioral therapy/techniques with plans to further work on the development of better coping skills.  A safety plan was in place with monitoring.  Treatment at the residential level proceeded with no biomedical complications or substance use, and she was deemed to be motivated to remain in treatment for the mental health disorders.  She was discharged on with plans for return to the home of her mother and continued services from community clinicians, as well as medication management.  The subject under review is the medical necessity for the inpatient residential treatment.

The health plan's determination is upheld.

In this case, the requested services can be safely and effectively provided at a lower level of care for the dates of time under review.  There were no remaining severe symptoms or safety concerns that would have required the continued residential level structure, monitoring or services.  The intensity of services and structure required in this case, could have been/can be provided at a lower level of care with boarding or housing and intensive treatment of the co-morbid psychiatric disorders.  The patient's psychosocial stressors were not so severe to prevent treatment from occurring at a lower level of care.  There are no acute general medical issues, no substance use disorders, and no other clinical features related to the co-occurring psychiatric disorders that required continued residential level treatment in this case scenario.  Thus, the requested treatment is considered not medically necessary in this case scenario.