Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Suicidal Ideation With Impairment In Functioning
Treatment: Mental Health Residential Treatment
The insurer denied the Mental Health Residential Treatment.
The denial is overturned. 

The patient is a male. He was admitted residential treatment center. The patient's parents write an undated letter of appeal stating that any services provided cannot be safely and satisfactorily provided at home or through the use of a virtual PHP (partial hospitalization program) model. During this week alone, they witnessed their son have a severe panic attack during a family therapy session, requiring the session to be stopped and his being removed from programming for the rest of the day. These panic attacks have resulted in past hospitalizations. The parents are not equipped to handle them at home.

The patient's current medication has recently been modified and his diagnoses are still unmanaged. He has also struggled greatly with his academics, resulting in a significant setback. Virtual models would require him to isolate in his room for at least eight hours per day, which would only exacerbate his symptoms of anxiety and depression. He also has a 504 plan around him being blind in one eye: long periods of screen time are detrimental to his visual health.

Another undated letter states that since the last letter, the patient has had several significant struggles, particularly with his medication. He has been experiencing dissociative feelings which leave him unable to do schoolwork or participate in some of the programming. It has brought back anxiety, OCD (obsessive compulsive disorder) and suicidal ideation. His Zoloft has been lowered twice over the past two weeks and a medication change is being considered. He is not stable.

Facility records indicate that the patient reports that his intrusive thoughts continue to be intense and constant and difficult to reframe. He states that he had a panic attack in the last family session, with sweating and hyperventilation. His mother's yelling affected him and he felt awful. The patient's therapist points out that the patient is now doing things differently and expressing himself instead of bottling things up. He has recently described dissociating more. The patient tries to control his mother's responses which perpetuates crippling anxiety. He struggles to stay present.

Yes, the Mental Health Residential Treatment is medically necessary.

Records indicate that the patient continues to display behaviors which are concerning for his ability to maintain safety, appropriately interact with others, and use treatment for further progress to be made. He discloses new information regarding Obsessive Compulsive Disorder symptoms which requires reassessment, changes his treatment plan and has a negative impact on his ability to function. He reports a pattern of unmanageable obsessive thoughts/ruminations tied to suicidal ideation. He is noted to be in danger of uncontrolled suicidal ideation until these symptoms are better controlled. He also reports apparent medication side effects which leave him struggling with dissociation, depersonalization and derealization.  At this time he also reports suicidal ideation. He is unable to engage in a family session due to his symptoms. The patient reports continuing dissociative symptoms and is unable to engage in an EMDR (eye movement desensitization and reprocessing) session.

The patient displays and reports significant symptoms, some newly disclosed, which require the intensity, structure and safety of residential treatment to be adequately assessed, monitored and treated.

The patient requires the intensity and safety of residential treatment in order to monitor him for suicidal ideation and behavior; provide a consistent, structured and intensive treatment environment for him to begin to acknowledge, address and stabilize significant symptoms, some newly disclosed, including obsessions, compulsions, suicidal ideation, dissociation, depersonalization and derealization; be monitored for medication changes which have led to significant symptoms and treatment disruption; and prepare him and his parents for understanding and coping with these symptoms/conditions prior to discharge.