Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Bipolar Disorder, ADHD (Attention Deficit Hyperactive Disorder), and Learning Disorder.
Treatment: Mental health residential treatment.

The insurer denied coverage for mental health residential treatment.  The denial is overturned.

This male was admitted to inpatient mental health residential treatment due to disruptive behavior, impulsivity, poor frustration tolerance, emotional dysregulation, depressed mood, hopelessness, guilt, concentration problems, suicidal thoughts, restlessness, cannabis use, poor and maladaptive coping skills, poor insight, blaming of others and not taking responsibility for his behaviors and actions. He did not improve after past traditional substance treatments in multiple settings. He had past hallucinations and paranoia. He had diagnoses of Bipolar Disorder, ADHD, and Learning Disorder. His discharge medications were Bupropion, Cariprazine, Depakote, Propranolol, and Melatonin. 
  
The Milliman Care Guidelines (MCG) Residential-Behavioral Health Level of Care- Psychiatry guidelines for adults report that one needs to have continued danger to self or others, moderately or severe psychiatric or behavioral symptoms requiring 24 hour daily treatment, or serious dysfunction in daily living. For discharge it states that there needs to be sufficient support at a lower level of care, absence of suicidal or homicidal thoughts or thoughts of harm to self or others. In this case this patient continued to have moderate psychiatric symptoms and limited coping skills putting him at risk for worsened mood symptoms and continued self-medication with substances. He was considered at risk of decompensation and relapse of drugs if discharged, as he still did not have adequate enough coping skills to function safely outside of this residential treatment setting. In this case this was a high-risk patient with poor coping skills and poor insight with neurodevelopmental delays in learning, who had depressive symptoms and still struggled with accepting responsibility for his actions and maladaptive interactions and functioning. 

The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patient's with Bipolar Disorder reports that the least restrictive setting for safe and effective treatment is appropriate. It also states that the general goals of bipolar disorder treatment are to assess and treat acute exacerbations, prevent recurrences, improve interepisode and provide assistance, insight, and support to the patient and family. It also states that subsequently, specific goals of psychiatric management include establishing and maintaining a therapeutic alliance, monitoring the patient's psychiatric status, providing education regarding bipolar disorder, enhancing treatment compliance, promoting regular patterns of activity and of sleep, anticipating stressors, identifying new episodes early, and minimizing functional impairments. In this case this patient benefitted from more time in a structured and supervised inpatient mental health therapeutic residential treatment to try to improve coping skills more, emotion regulation, anger control, social interactions and relations, insight, decision making, decrease impulsivity, and transition back into the community and home. It was reported that the staff and family did not feel that this patient was ready for discharge and needed more time to sustain past gains and have more gains to better ensure that he would be safe and not have suicidal thoughts, maladaptive behaviors or coping skills. He required more time in this mental health residential treatment setting as past traditional substance use settings were not effective. 

The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for mental health residential treatment is overturned. Medical Necessity is substantiated.