Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Disruptive mood dysregulation disorder (F34.81), generalized anxiety disorder (F41.1) and cannabis use disorder (F12.20).
Treatment:  Residential Mental Health Treatment with 24 hour/day Support.

The insurer denied Residential Mental Health Treatment with 24 hour/day Support.  The denial is upheld.

The patient is a teenage male. He was admitted to a behavioral health residential treatment level of care. He was diagnosed with disruptive mood dysregulation disorder (F34.81), generalized anxiety disorder (F41.1) and cannabis use disorder (F12.20). Other diagnoses indicated include alcohol use disorder, attention deficit hyperactivity disorder, executive function deficits, and unspecified neurocognitive disorder.  Continued behavioral health residential treatment level of care for 5 months was noted to have been previously denied as not medically necessary. The patient was noted to have been stable with no significant ongoing symptoms that required a 24-hour structured setting for continued treatment.

The requested Residential Mental Health Treatment with 24 hour/day Support was not medically necessary.

Based on current evidence-based medical literature, the proposed treatment (continued behavioral health residential treatment) was not found to be medically necessary. The clinical information provided does not indicate that the service requested was the least restrictive setting that was medically necessary or was likely to be successful in treating the patient's symptoms (1-9).

The clinical information reviewed indicates that the patient had no significant ongoing behavioral health symptoms that required a 24-hour structured setting for continued treatment. The patient was noted to have intermittent episodes of irritability and some persistent anxiety and mood symptoms, which were noted to be his baseline and did not represent a significant change. 

The patient was not reported to have any suicidal or homicidal ideations or found to be at risk of harm to self or others. He was not reported to have any symptoms suggestive of psychosis including hallucinations, delusions, or paranoia. He was not reported to have any significant symptoms suggestive of mania or hypomania. He was not reported to have exhibited any significant and persistent agitation or aggressive behaviors. The patient was not reported to have engaged in any self-injurious behaviors recently and was not reported to have any significant urge. The patient was not reported to have any significant ongoing medical conditions that required interventions or monitoring. He was not reported to have any significant adverse effects from any prescribed psychotropic medications. The patient was not reported to have any significant functional impairments including age-appropriate activities of daily living or self-care that represented a change from his baseline. There was no indication that the patient had any significant barriers to treatment in the community including severe ongoing psychosocial stressors, unsafe living environment or lack of social support. There was no indication that the patient had any significant exacerbation or emergence of new symptoms for the rest of his stay at the residential treatment level of care. There was no indication that the patient continued to exhibit improvements in behavior with ongoing treatment at the residential treatment level of care. The clinical information reviewed indicates that the patient may have been treated safely and effectively in a less restrictive setting and lower level of care.