Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Anxiety and Depressive Disorders.
Treatment: Continued Residential Mental Health Treatment.
The insurer denied Continued Residential Mental Health Treatment.
The determination is overturned.


The patient completed a Wilderness Program and was referred for residential treatment of co-occurring anxiety and depressive disorders (severe and recurrent major depressive disorder, persistent depressive disorder, social anxiety disorder, and generalized anxiety disorder); attention deficit hyperactivity disorder (ADHD)-combined type; and autism spectrum disorder (ASD) together with academic and educational problems associated with emotional abuse including bullying by peers. The patient has had increasing symptoms related to the co-morbid psychiatric conditions in the context of high- risk behaviors that have included self-harm with cutting and suicidal behavior/attempts requiring emergency medical services and psychiatric hospitalization. The patient's autism spectrum disorder is associated with problems with social skills and sense of self with low self-worth and a tendency toward impulsive aggression towards self and emotional dysregulation. The patient's mental health disturbances emerged at an early age with an increasing severity of symptoms and behavioral disturbances that included high risk behaviors with bouts of self-harm and suicidality with associated interpersonal relationship problems resulting in loneliness and social isolation.
The mental status examination at the time of admission for residential treatment revealed severe symptoms of anxiety, depression, low self-worth, and affective instability together with suicidal ideation associated with guilt and shame. He had trauma-related symptoms, as well as disturbed sleep. There were prominent issues with regard to peer relationships and a lack of insight together with impaired judgment and poor control of impulses. He reported panic attacks and paralyzing anxiety when in a social setting including apprehension, nervousness, tension and irritability.
Past psychiatric treatment with inpatient, outpatient and intermediate levels of care had failed to provide benefit or remission or sustained benefit despite the best effort of clinical providers. Thus, he was referred to the Wilderness Program followed by the referral for extended residential level services.
There were no acute medical conditions or current substance use disorders in this case though the patient has a history of alcohol and cannabis use disorders (in remission). The patient is a student and lives with family. The patient's academic functioning had declined as well as his attention to self-care and daily activities.
The patient presented for residential treatment and received comprehensive evaluations that affirmed the comorbid diagnoses. Records show that the patient initially participated in group, individual, family and other therapies focusing on coping skills and maintaining safety with monitoring. He received milieu, therapeutic and academic programming. The patient made steady progress such that he was able to reduce his tendency to engage in self-destructive behaviors though he continued to report suicidal ideation driven by interpersonal relationship problems and moderately severe symptoms of depression with a Patient Health Questionnaire (PHQ)-9 determination averaging at 15 in association with depressive ruminations. The patient continued to show relationship issues with peers and affective instability with associated symptoms of anxiety and depression-a focus of treatment. The patient received treatment with psychotropic medication that included ketamine treatment targeting depression and suicidality, and as needed (prn) use of propranolol for social anxiety and panic. He was working on coping skills and use of modified dialectical behavioral therapy (DBT) with distress tolerance, mindfulness and emotional regulation techniques. Going forward during this time interval, the treatment plan called for continued active treatment targeting life skills, social skills, and trauma recovery, as well as involvement with academic programming focused on obtaining his GED [General Educational Development] and with mentoring. The patient was also participating in more intensive illness recovery services and family-focused sessions. These additional services were provided, as well as other therapeutic interventions as the program would allow that were age appropriate. The treatment plan included educational and peer support sessions; psychotherapy, as noted; and other activity therapies to address relational functioning; and family-focused sessions with encouragement to include his primary source of support, his mother, in the sessions. Safety monitoring was provided within the structure of the residential program.
Because of developmental disorder and the childhood trauma due to bullying, the patient had not developed secure attachments that had affected the patient's core beliefs about the world and self. The treatment focused on the patient's belief that he was bad, and that is why he had been abused or was bullied. The treatment plan in this case provided for active treatment to remedy to this belief system and the painful situations that arise as a consequence leading to suicidal risk and self-harming behavior. Thus, the core treatment with the continued use of therapy and medication and activities focused more on a relationally based treatment model. As noted, the patient's family-focused sessions were evolving to address the plan for reunification with the family and ongoing support with clinically appropriate aftercare in the community. The patient was actively participating in a recovery process with focus on the development of better coping skills and relational functioning. There were no complications of treatment reported in this case with regard to safety issues or a recrudescence of high-risk behaviors in the context of 24-hour monitoring and a safety plan to continue following discharge.
The health plan documents were reviewed including correspondence, case notes, and health plan medical necessity criteria (InterQual). Letters from the treatment facility and parent were reviewed with appeal. The health plan's rationale for the denial of authorization for continued residential coverage was reviewed. The denial was on the basis of InterQual Criteria for Adult and Geriatric Patients indicating that the patient had no impairment of functioning, no moderately severe symptoms, no eating disorder, no interpersonal conflict and the ability to cooperate with treatment.
The appeal referenced the moderately severe symptoms of depression and comorbidities with high risk for suicide including active suicidal ideation and history of suicidal behavior, as well as the substantial interpersonal relationship problems and history of being bullied together the decline in academic functioning.
At issue is the medical necessity of Continued Residential Mental Health Treatment.
The requested health service/treatment of mental health residential stay  was medically necessary for this patient.
The patient's symptoms, clinical features and treatment dimensions did warrant continued residential level care. They could not have been safely or effectively managed with lower-level services or in a less restrictive treatment setting.
The patient remained symptomatic with the need for continued residential treatment and structure and monitoring in order to address residual symptoms of anxiety and depression, trauma-related symptoms, and the need for ongoing psychiatric management together with the family focused and relational-based interventions that were occurring to address the psychological factors in this case.
The patient had multiple co-occurring disorders and was at high risk for relapse. The patient has failed to benefit from clinically appropriate treatment at lower levels of care, and represented a safety risk to self. It is not reasonable to expect that the patient could have been safely or effectively managed with lower-level services in a less restrictive level of care for the time frame under review.
The diagnoses per the treatment plan and psychiatric evaluations included sufficient clinical information in the patient's medical records to support the diagnoses in this case including the relational problems, as well as the neurocognitive deficits, autism and ADHD. The patient's conditions are considered moderately severe, especially with regard to the anxiety and mood disorder; the trauma-related problems; and the social relational problems associated with high-risk behaviors including past episodes of self-harm and impulsivity and suicidal behavior. The safety concerns; risk for relapse; and risk factors with regard to the history of high-risk behaviors did necessitate that the patient receive the continued structure, intensity and monitoring provided within a residential treatment setting consistent with generally accepted standards of medical practice, and the societal guidelines referenced below and applicable to an adolescent, as in this case. 
This answer is consistent with the societal guidelines and scientific literature referenced below, as well as prevailing standards of medical practice.