Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 

The patient is a 24-year-old female with diagnoses of borderline personality disorder, major depressive disorder, and generalized anxiety disorder. In April 2019, after an argument with her boyfriend, she became suicidal, with the plan to jump off a freeway overpass. The physician reviewer found that the American Psychiatric Association has developed clinical guidelines for the treatment of patients with borderline personality disorder. Per the APA, Clinical experience suggests that most patients with borderline personality disorder will need some form of extended psychotherapy in order to resolve interpersonal problems and attain and maintain lasting improvements in their personality and overall functioning. The APA guidelines note, Two psychotherapeutic
approaches have been shown to have efficacy in randomized controlled trials: psychoanalytic/psychodynamic therapy and dialectical behavior therapy. Per the guidelines, Indications for extended inpatient hospitalization include the following: persistent and severe suicidality, self-destructiveness, or non-adherence to outpatient treatment or partial hospitalization; comorbid refractory axis I disorder (e.g., eating disorder, mood disorder) that presents a potential threat to life; comorbid substance abuse or dependence that is severe and unresponsive to outpatient treatment or partial hospitalization; continued risk of assaultive behavior toward others despite brief hospitalization; and symptoms of sufficient severity to interfere with functioning, work, or family life that are unresponsive to outpatient treatment, partial hospitalization, and brief hospitalization.
The American Association of Community Psychiatrists Level of Care Utilization System for Psychiatric and Addiction Services (LOCUS) is a beneficial tool in determining the appropriate level of care. The (AACP) has developed guidelines for determining the appropriate level of care for patients with mental health symptoms. In this case, with regard to risk of harm, the records support a score of 2. The patient had a low risk of harm, due to transient active suicidality with a plan in the recent past, without current active suicidal or homicidal ideation, plan, or intent, or acute distress. In terms of functional status, the records support a score of 3. The patient had moderate impairment, due to conflict with parents and difficulty maintaining a job or completing college. With regard to comorbidity, the records support a score of 1. The records document the absence of substance abuse or major medical illness. In terms of level of stress of the recovery environment, the records support a score of 3. The documentation noted family discord and inability to fulfill work or academic expectations. The records noted her parents attempts to arrange treatment for the patient. In terms of treatment and resiliency history, the records support a score of 3. The patient had moderate or equivocal response to treatment due to continued symptoms despite past treatment, which was brief, not extended. With regard to engagement and recovery status, the records support a score of 2 due to motivation to continue treatment. In terms of engagement, the records support a score of 2. Therefore, the patient has a total score of 16.
Per the LOCUS guidelines, the appropriate level of care at the time of admission to the residential treatment center was high-intensity community-based services. Additionally, the patients records do not provide clinical documentation of why she was discharged from intensive outpatient program treatment and enrolled in a residential treatment center in June 2019. Therefore, residential treatment provided from 6/19/19 through 7/24/19 was not medically necessary for the treatment of this patient.