Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Mental Health/Depression.
Treatment: Mental Health/Residential Treatment.
The health plan denied the requested residential treatment as not medically necessary. 
The health plan's determination is overturned.

The case involves an adult male who was admitted to residential level services with severe symptoms of depression and anxiety associated with severe psychosocial stressors and the inability to function. The patient's admission had been precipitated by worsening symptoms of depression and anxiety in the context of treatment refractory depression, a near-lethal suicide attempt resulting in a spinal cord injury and other medical complications and associated with moderately severe stimulant use disorder with prescription amphetamines.
The patient has a history of severe and recurrent major depressive disorder with anxious distress and attention deficit hyperactivity disorder (ADHD) inattentive type associated with stimulant use. The patient has a history of prior psychiatric treatment that failed to produce a sustained response including two psychiatric hospitalizations for depression, suicidal behavior and psychosis. The onset of stimulant use and occasional use of alcohol began in adolescence and escalated while in college. There were no acute general medical issues. However, the patient had a spinal cord injury after jumping from a parking garage with bladder problems and incontinence, as well as chronic pain with leg spasms treated with Baclofen. Prior treatment had included dual diagnosis Intensive Outpatient Program (IOP) and outpatient level treatment, as well as the hospitalizations.
The patient is single, a student and is on medical leave.
Mental Status Examination on admission: The patient was cooperative and guarded with anxious and depressive demeanor. He displayed depressed mood with anxiety and slowed mentation that included cognitive clouding. He had decreased concentration, energy, appetite, and volition with hypersomnia and a tendency to isolate socially. His speech was coherent with organized thought processing. Insight and judgment were limited and impaired. He displayed hopelessness, helplessness, and self-reproach indicating that he was having fleeting thoughts of suicide or urges to self-harm.
The patient was admitted to residential level care with a treatment plan that included safety-monitoring, access to group and milieu therapies, intensive individual dynamic therapy, and medications to address the mood disorder. The patient was initially noted to be severely depressed and socially withdrawn. He was increasingly cooperative with staff and was medication adherent; he tended to isolate with social withdrawal and modest, but reasonable participation in the therapeutic activities with a lack of motivation and neglect of basic self-care requiring reminders and monitoring. The patient was treated with Rexulti, Trintellix, and Wellbutrin at clinically appropriate dosages, with past genetic testing showing that he was slow metabolizer.

The health plan's determination of medical necessity is overturned, in whole.

Yes, the requested health service/treatment of residential treatment was medically necessary for this patient.
The patient could not have been safely or effectively managed within a less restrictive setting or with a lower level of care during the time interval under review. The appeal appropriately provided the application of LOCUS Guidelines indicating that the patient was at high risk for harm, had severe functional impairments, had significant medical and substance-related comorbidities, had a recovery environment that had failed to provide a sustained therapeutic response, and had treatment refractory depression with limited prior engagement with treatment, warranting the continued residential treatments.