Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Suicidal Ideation
Treatment: Residential Mental Health Treatment with 24-Hour a Day Support
The insurer denied: Residential Mental Health Treatment with 24-
Hour a Day Support
The denial is upheld.

The patient is a teenage female for whom admission to a behavioral health residential treatment level of care was requested. She was reported to have been diagnosed with posttraumatic stress disorder (F43.10), unspecified eating disorder (F50.9), and disruptive mood dysregulation disorder (F34.81). Other diagnoses indicated in the discharge summary include major depressive disorder and generalized anxiety disorder. The admission was noted to have been requested for persistent symptoms of irritability, anger, agitation, mood dysphoria, depression, anxiety, and suicidal ideations in the context of significant psychosocial stressors including conflicts with caregivers. This review pertains to the medical necessity of treatment at the behavioral health residential treatment level of care for 14 months, which was noted to have been previously denied as not medically necessary. 

The requested behavioral health residential treatment level of care was 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 (1-8). The patient is a teenage female for whom admission to a behavioral health residential treatment level of care was requested. She was reported to have been diagnosed with posttraumatic stress disorder (F43.10), unspecified eating disorder (F50.9), and disruptive mood dysregulation disorder (F34.81). Other diagnoses indicated in the discharge summary include major depressive disorder and generalized anxiety disorder. The admission was noted to have been requested for persistent symptoms of irritability, anger, agitation, mood dysphoria, depression, anxiety, and suicidal ideations in the context of significant psychosocial stressors including conflicts with caregivers. 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 a 24-hour structured setting for treatment of behavioral health symptoms at the time of her admission. She was reported to have intermittent episodes of irritability and mood dysphoria that were noted to be her baseline and did not represent a significant change. The patient was not reported to have any suicidal or homicidal ideations or found to be at risk of harm to self or others at the time of her admission or immediately prior to her admission. The patient was not reported to have any significant ongoing medical conditions that required intervention or monitoring. She was not reported to have any significant adverse effects from any prescribed psychotropic medications. She was not reported to have any significant barriers to treatment in the community including severe ongoing psychosocial stressors, unsafe living environment, or lack of social support. There was no evidence that the patient required a 24-hour setting with medical and nursing monitoring for treatment of her ongoing symptoms. The clinical information reviewed indicates that the patient may have been treated safely in a less restrictive setting and lower level of care such as a day treatment program (partial hospitalization program).