Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Persistent behavioral problems. 
Treatment: Mental Health Residential Admission. 

The insurer denied the Mental Health Residential Admission. 
The denial is upheld. 

The patient is a female who was admitted to a behavioral health residential treatment level of care. She was reported to have been diagnosed with other specified depressive disorder (F32.89), other specified attention deficit hyperactivity disorder (F90.8), other specified anxiety disorder (F41.8), and specific learning disorder with impairment in mathematics (F81.2). She was reported to have been admitted for persistent behavioral problems, anger, irritability, anxiety and depression. This review pertains to the medical necessity of continued residential treatment level of care. The request for continued treatment was noted to have been previously denied as it was not found to be medically necessary.

The patient was reported to have a history of behavioral health treatment in the past including an inpatient psychiatric hospitalization two years prior. She was reported to have an extensive history of outpatient psychotherapy. She was reported to have a history of suicidal thoughts in the past. The patient was reported to have a history of oppositional and defiant behaviors including stealing and lying. There was no indication of the patient had any significant ongoing medical conditions that required interventions or monitoring. There was no indication of the patient had any significant ongoing substance abuse. The patient was provided with individual, group, and family therapy while in residential treatment. She was noted to have been prescribed psychotropic medications including lamotrigine and sertraline. Medications were noted to have been optimized for adequate symptom control. The patient was not reported to have any significant adverse effects from prescribed 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 her baseline. She 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 any prescribed medication. There was no indication of the patient had any significant barriers to continuing treatment in the community including severe psychosocial stressors or unsafe living environment. 

No, the Mental Health Residential Admission is not 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. 

Treatment at a residential level of care with a 24-hour structured setting is required when there are significant safety concerns that require daily monitoring, significant functional impairments related to behavioral symptoms including impairments in self-care and activities of daily living, or significant substance use affecting daily functioning (1-9). Such symptoms include persistent low mood, agitation, aggression (1, 4, 7), persistent active suicidal ideations, symptoms of psychosis or mania, and continued substance use affecting physical and emotional health. 

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 or found to be at high risk of harm to self or others. She was not reported to have any symptoms suggestive of psychosis including hallucinations, delusions, or paranoia. She was not reported to have any significant symptoms suggestive of mania or hypomania. The patient was reported to have intermittent symptoms of irritability and mood dysphoria which appeared to be her baseline and did not represent a significant change. She 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 urges. 

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 her baseline. She 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 any prescribed medication. There was no indication of the patient had any significant barriers to continuing treatment in the community including severe psychosocial stressors or unsafe living environment. The clinical information reviewed indicates that the patient may have been treated safely in a less restrictive setting and lower level of care. Therefore, continued residential treatment level of care was not found to be medically necessary. 

Yes, the health plan did act reasonably, with sound medical judgment, and in the best interest of the patient. 

The patient is a female . She was reported to have been diagnosed with other specified depressive disorder (F32.89), other specified attention deficit hyperactivity disorder (F90.8), other specified anxiety disorder (F41.8), and specific learning disorder with impairment in mathematics (F81.2). She was reported to have been admitted for persistent behavioral problems, anger, irritability, anxiety and depression. 

Clinical documentation reviewed does not indicate that the patient had any significant ongoing behavioral health symptoms that required continuing 24-hour structured setting of a residential treatment level of care. The patient was not noted to be at persistent risk of harm to herself or others. She was not noted to have any severe behavioral symptoms including symptoms suggestive of psychosis or mania. There was no indication of the patient had any adverse effects from prescribed medications. She was not reported to have any significant functional impairments including age-appropriate activities of daily living and self-care that represented a change from her baseline. The patient was not reported to have any significant barriers to treatment in the community including severe psychosocial stressors or unsafe recovery environment. The patient may have been treated safely and effectively in a less restrictive setting and lower level of care. Therefore, the health plan did act reasonably, with sound medical judgment and in the best interest of the patient while denying continued coverage for residential treatment level of care.