Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Recurrent Major Depressive Disorder, Obsessive Compulsive Disorder
Treatment: Continued Inpatient Mental Health Services
The insurer denied the Continued Inpatient Mental Health Services.
The denial is upheld.

The patient is a female who was admitted to inpatient psychiatric unit.

Emergency Department records indicate that 911 was activated by the neighborhood due to a verbal altercation between the patient and her mother. Her mother reports that her daughter has been regressing in terms of her self care for several years: she has been eating less, and is scared to wash her face or hands. She has been washing her hands one to two times an hour which gradually subsided until the pandemic started. It reemerged then and became worse in the past one to two months. She starts thinking about being dirty and needs a lot of reassurance from her mother. She showers every three days and resists brushing her teeth because she feels that the bathroom is dirty. She avoids touching her shoes. She did not leave the house for two months because of contamination fears. She has been seeing an outpatient therapist twice a week but refuses psychiatric treatment. She is transferred for inpatient admission. 

Inpatient records indicate that the patient is calm and cooperative. She attends school and group activities and participates. She interacts well with peers. She denies suicidal and self harm ideation. She is in good behavioral control. She has a good visit with her mother. She showered and attended groups with no behavioral dysregulation. She maintained safe behavior. She was calm and cooperative. She was visible in the milieu and was more engaged, verbal and interactive. She denied suicidal ideation and contracted for safety. No agitation was noted. Her affect was fair. The patient was calm and cooperative. She listened to staff and followed unit routines. She showered and was visible and interactive in the community. By report she continued to spend excessive amounts of time washing her hands in the bathroom. She has been responding to redirections from staff. She denies suicidal ideation, dysphoric mood, anhedonia and hopelessness. She is eating and sleeping well and participating appropriately. There are no medication side effects. No medication changes were made. Her affect was bright. A visit with her mother went well. She showered. She was in good behavioral control. It was noted that during that week she has remained in good behavioral control with no aggressive or self harm behaviors. She continued to attend daily groups although she did not verbally share her feelings. She was calm in the community but was mainly to herself. She achieved level II. She stated that she was continuing to avoid touching a toothbrush after it fell on the ground two days go. She was unwilling to use this as an exposure opportunity. She continued to display minimal insight into her issues. Her affect was bright. She has been accepted at a Partial Hospital Program (PHP). 

The patient was calm, cooperative and compliant. She showered. She interacted minimally with peers. She interacted well with others and attended groups. She denied suicidal ideation. Lexapro would be increased. She was noted to continue to spend excessive amounts of time washing her hands in the bathroom. She was sleeping and eating without difficulty. She participated appropriately in groups. There are no medication side effects.  She showered and attended groups. She interacted well with peers. A visit with her mother went well. She showered. She maintained good behavioral control. No excessive washing of hands was noted. She was calm and cooperative. She showered. She maintained good behavioral control. She talked about her history of compulsive behaviors. She stated that she continues to have difficulty washing her hands in the shower. She is receptive to placing limits on the amount she washes her hands in the sink She has been tolerating the increased Lexapro dose well. She continues to express worries about contamination and some compulsive handwashing but is able to respond to them with redirection. She has no difficulty eating or sleeping. She engages in groups and interacts appropriately. The patient is calm and in good control. She showered. She was complaint. She attended school and participated. A discharge summary states that during her stay she gradually opened up to the team, consistently participated in daily individual therapy and groups, and maintained good behavioral control. She consistently denied suicidal and homicidal ideation. She was looking forward to discharge home and continuing treatment in a partial hospital program (PHP).

No, the proposed treatment is not medically necessary.

There is no evidence that the patient requires the restrictiveness, intensity and safety of inpatient treatment. She does not engage in any unsafe behavior toward herself or others and denies suicidal and homicidal ideation. She does not require intensive staffing to keep her safe or engaged in treatment. She has no medical issues and no medication side effects. She engages consistently in treatment and activities. While she reports that she continues to struggle with some obsessions and compulsions, they are not affecting her ability to engage in daily activities or self care. She showers regularly. Her sleep and appetite are good. There is no indication that she misses any activities due to engaging in compulsive behaviors or that she is harming herself or anyone else in any way due to these behaviors. There is minimal evidence of Exposure Response Prevention treatment being applied during her admission; treatment in a less restrictive environment would be safe and could be more effective in treating her condition.

The patient did not require inpatient level of care and could have been safely and effectively treated in a lower level of care.