Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Obsessive-compulsive disorder,
schizoaffective disorder, bipolar type and
cannabis use disorder
Treatment: Inpatient Behavioral Health Service
The insurer denied the Inpatient Behavioral Health Service
The denial is upheld

The patient is a male who was admitted to a behavioral health residential treatment level of care. He was reported to have been diagnosed with obsessive-compulsive disorder, schizoaffective disorder, bipolar type and cannabis use disorder. The patient was reported to have been admitted for persistent symptoms of psychosis, disorganized behaviors, irritability and mood dysphoria in the context of psychosocial stressors and persistent cannabis abuse. This review pertains to the medical necessity of behavioral health residential treatment level of care.

The patient was reported to have a history of behavioral health treatment of the past including inpatient behavioral health hospitalizations. An appeal letter provided by the treating provider indicates that the patient was initially admitted to an acute inpatient psychiatric unit for a severe psychotic episode. The patient was reported to have been stepped-down to an intensive outpatient level of care followed by partial hospitalization program (PHP). The patient was reported to have attended a schizophrenia rehabilitation partial hospitalization program (PHP) for approximately six months prior to admission to the residential treatment level of care. An appeal letter provided by the patient's treating psychologist indicates that the patient was initially referred for increasing distress and depression with suicidal ideations. The patient was reported to have been admitted to a residential treatment setting at which time the provider was noted to have worked for the family to increase monitoring and support.

Based on current evidence-based medical literature, the requested service (mental 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.
The clinical information reviewed indicates that the patient had no significant ongoing symptoms that required residential treatment level of care. The patient was not reported to have any suicidal or homicidal ideations with plans or intent. There was no indication that the patient continued to be at high risk of harm to self or others. He was not reported to have any significant ongoing symptoms suggestive of psychosis including hallucinations, delusions, or paranoia. He was not reported to have any significant symptoms suggestive of mania or hypomania. The patient was noted to have intermittent episodes of irritability and mood dysphoria which are described as his baseline and did not represent a significant change. There was no indication of the patient had engaged in any self-injurious behaviors.

The patient was not reported to have any ongoing medical conditions that required interventions or monitoring. The patient was not reported to have any significant adverse effects from prescribed medications. There was no indication that the patient had any significant symptoms of substance use disorder including cannabis that required a 24-hour structured setting for continued treatment. The patient had no significant functional impairments including activities of daily living or self-care that indicated a change from his baseline functioning. There was no indication that the patient continued to exhibit improvement in behavior with ongoing treatment at the residential treatment level of care. There was no indication that the patient had any significant barriers to continuing treatment in the community including severe psychosocial stressors or unsafe living environment. Therefore, based on current evidence-based medical literature, the requested service (mental health residential treatment) was not found to be medically necessary.

Clinical documentation reviewed does not indicate that the patient had any significant ongoing symptoms that required the 24-hour structured setting of a residential treatment level of care. The patient is a male who was noted to have been admitted to a behavioral health residential treatment level of care. He was noted to have been diagnosed with schizoaffective disorder, bipolar type, obsessive-compulsive disorder and cannabis use disorder. The patient was noted to be largely stable and at his baseline with no significant ongoing behavioral health symptoms that required continuing treatment at the residential treatment level of care. The patient was not noted to be at risk of harm to himself or others. He was not reported to have any ongoing symptoms suggestive of psychosis or mania. There was no indication of the patient had any significant functional impairments including activities of daily living or self-care that represented a change from his baseline. He had no ongoing medical conditions that required interventions or monitoring. The patient may have been treated safely and effectively in a less restrictive setting and lower level of care such as a day treatment program. Therefore, the health plan was noted to have acted reasonably and with sound medical judgment, in the best interest of the patient in denying coverage for continued residential treatment level of care.