Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Obsessive compulsive disorder
Treatment: Psychiatric residential treatment center care
The insurer denied: Psychiatric residential treatment center care
The denial is overturned.

The case involves an adult female diagnosed with severe obsessive-compulsive disorder (OCD) and comorbid symptoms of anxiety and depression (social phobia and agoraphobia) with 
fear of contamination and extensive cleaning rituals with excessive time showering. The patient has not responded to prior treatments with inpatient, partial hospital program, and outpatient programs targeting obsessive compulsive disorder. Moreover, the patient has declined in functioning with daily activities and social and educational functions not having attended school for two years and not wanting to go outdoors. The patient was referred and admitted to a specialty residential psychiatric treatment facility 6 months ago with an administrative discharge last month due to the facility's COVID-19 protocol and a COVID-19 outbreak with return to the program earlier this month with resumption of 
residential treatment. Her admission had occurred despite treatments in the community such that the patient continued to have severe symptoms of anxiety, compulsive rituals, and intrusive thoughts; and, she had a significant decline in functioning-as noted, such in that she was unable to function socially, or at times had been unable to do basic self-care. The patient had been in outpatient mental health treatment that included therapy and medications, prior to her referral for more intensive and structured treatment that was recommended by community providers. Mental Status Examination included obsessive-compulsive related symptoms including rituals and obsessive anxiety together with agoraphobia, anxious and dysphoric mood with affective instability and elements of panic, and, social phobia, as well as illness anxiety due to fears of 
contamination. She had limited insight and judgment that was impaired due to her multiple conditions/symptoms together with maladaptive coping and dependency. The patient is single and lives with her parents. From earlier this month forward, the patient resumed treatment and prior to the administrative 
discharge, she was making progress with her goals and participating in intensive treatment, as indicated. However, she had regressed during the ten-day treatment hiatus, and she continued to struggle with symptoms related to anxiety and obsessive-compulsive disorder with ongoing risk for prominent compulsive rituals, lengthy showering, and a continued lack of skills and insight. Going forward with her residential treatment, the patient had previously engaged more and more effectively in treatment with sustained improvement and setbacks during the treatment gap. Family focused feedback sessions were occurring with identification of family issues and triggers, as well as focus on coping skills. Thus, she was making progress in this regard with improvements with mood and interpersonal functioning and diminished levels of anxiety according to submitted information. 
The treatment plan included plans for step down with continued partial hospitalization program (PHP) level treatment of the obsessive-compulsive related disorder, as well as ongoing care to address her residual effects of the catastrophic illness she had incurred including the ongoing recovery from the symptoms of anxiety and depression.

The requested health service/treatment of psychiatric residential treatment was/is medically necessary for this patient.

The patient's re-admission and continued residential level treatment is reasonable and warranted as noted in the appeal; she continued to display severe symptoms of obsessive-compulsive disorder (OCD) and associated symptoms of anxiety and depression together with distress problems, interpersonal functioning problems and decline or impairment of functioning that had deteriorated to the point that she was unable to benefit from treatment at lower levels of care. She continued to display coping deficits and a lack of insight that did warrant the structure, 
monitoring, and intensity of treatment for the duration of the residential stay. The patient could not be effectively managed at a lower level of care in a less restrictive treatment setting during 
the time interval under review. Moreover, the patient had a reasonable likelihood of responding to the treatment and program of services provided by the residential treatment program, as described in the appeal. The requested benefit is therefore considered medically necessary.