Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Severe Depression, obsessive compulsive disorder, post-traumatic stress disorder (PTSD). 
Treatment: Mental Health Residential Treatment. 

The insurer denied the Mental Health Residential Treatment. 
The denial is overturned. 

The patient is a female who was referred for residential mental health treatment for a severe and recurrent mood disorder, obsessive-compulsive related disorder, and trauma-related symptoms resulting from sexual assaults and triggered by recent workplace trauma witnessing the death of COVID-19 cases. The patient has no co-occurring substance use disorder. The patient is described as having an anergic depression with vegetative symptoms impacting energy, interest and volition. Mood is dysphoric and affect is anxious together with a history of trauma and social anxiety disorder or avoidant behaviors and obsessive-compulsive related symptoms with checking and ordering rituals. 

The patient has had suicidal behavior including three inpatient psychiatric hospitalizations, as well as partial hospital program (PHP) and outpatient treatment with a recurrence and worsening symptoms of depression in the year prior to admission. Despite treatment with outpatient therapy and antidepressant medications, the patient's mood and comorbid disorders had worsened with persistent and intermittent suicidal ideation with a plan to overdose, self-harm with scratching arms and impairment of functioning. She had dropped out of school and was socially isolated with no or little supports. There is no mention of mania, thought disorder or psychosis. However, the patient does dissociate when experiencing trauma-related symptoms. Insight and judgment are limited and fair due to the multiple psychiatric conditions and treatment resistance or recurrence of symptoms. 

The program focuses on organizational skills; self-care; peer relationships; and coping skills as well as behavioral and emotional regulation with stress management, cognitive behavioral or dialectical behavioral techniques (CBT & DBT). Nutritional supports were provided to facilitate health eating. 

The patient struggled during the first several weeks of treatment and then began to actively participate in the treatment. The patient was noted to be flat with blank stares with high anxiety and little interaction with peers. She appeared tired and depressed, and apprehensive and tense with self-harming behavior and persistent suicidal thoughts. She continued to have urges to self-harm with was at high risk for suicide. 

The patient was prescribed medications that were being titrated as clinically appropriate, including Effexor XR, Prozac, Rexulti, Lithium, Neurontin, Prazosin and Seroquel withas needed (PRN) use of Vistaril for anxiety and insomnia, as well as supplements and vitamins. The patient was noted to be non-adherent to medications at times requiring monitoring and encouragement. 

The patient was increasingly engaged in treatment, but tended to isolate socially often reading or staying to herself. She made slow progress and struggled to achieve emotional regulation. The patient was engaged with the continued use of dialectical behavioral techniques (DBT) and cognitive behavioral therapy (CBT) while maintaining a therapeutic alliance and focus on the disordered eating with more intensive treatment. Medications were continued and had been titrated with monitoring with the addition of Cytomel and Modafinil. The patient made steady progress with discharge and step down to lower level care with a treatment plan that called for continued intensive treatment to address the multiple comorbid psychiatric disorders with safety monitoring and family support/involvement as clinically appropriate. 

Yes, the proposed treatment was medically necessary for this patient. 

The admission and continued residential services were clinically appropriate and not amenable to treatment at a lower level of care, and therefore, are not excluded under the plan, as medical necessity is met under the plan. During the time interval under review the patient was working to learn improved coping skills and life skills together with the development of improved insight and motivation, as well as family involvement. She did need the admission and did warrant the continued structure and monitoring of a residential setting in order to safely continue mental health treatment and services while maintaining safety with high risk for self-harm or suicide. There were severe psychiatric symptoms including complications related to trauma history, as noted in the clinical summary. Thus, the requested services are clinically appropriate and consistent with prevailing standards of professional practice and consistent with published practice guidelines (best practice) referenced below, as well as the plan coverage language and NY State instruction for this review. 

The patient needed the continued structure and monitoring of a residential setting in order to effectively address the risk of relapse, continue to learn adequate coping skills to engage in therapy, and prevent treatment failure, while the treatment team worked toward a clinically appropriate disposition, as well as working on trauma and obsessive compulsive disorder (OCD)-related symptoms with evidence-based interventions. The patient has demonstrated nihilistic behaviors including medication non-adherence and self-harming behavior that did require ongoing residential structure and monitoring with active treatment to address coping skills and symptoms related to the trauma/injury and the mood and obsessive compulsive disorder and anxiety disorders. The patient's lack of awareness or limitations of insight and impulse control, together with the seriousness of her mental health disorders are pertinent treatment factors that warranted the continued residential level services, despite having access to treatment in the community. The psychiatric symptoms of trauma, depression, anxiety, and stress within the social environment including a significant trauma history complicates this case, as the patient has symptoms that are triggering the risk for suicidal or self-harming behaviors. These factors support the assertion that the patient could not have been/cannot be effectively treated with a lower level of care going forward. These clinical factors needed to be effectively addressed prior to step down to a lower level of care.