Appeal type: Medical necessity
Decision: Overturned


Diagnosis: Trauma-Related Symptoms
Treatment: Inpatient Mental Health Services
The insurer denied Inpatient Mental Health Services
The determination is overturned.

The patient presented for partial hospital program treatment to address generalized anxiety disorder, major depressive disorder, post-traumatic stress disorder, social anxiety disorder, body dysmorphic disorder and specific phobia. The patient also presented with co-occurring substance use disorder with misuse of benzodiazepines and intermittent use of cannabis. The presentation included worsening symptoms of depression and anxiety with suicidal ideation, a decline in functioning and social isolation, in part due to the pandemic. The patient had no history of psychiatric hospitalization or suicidal behavior; they had an extensive history of outpatient treatment with medication management and psychotherapy. The trauma was related to a sexual assault in high school, as well as witnessing friends who were sexually assaulted.

The patient had severe symptoms of depression, anxiety and anhedonia together with trauma related symptoms evidenced by flashbacks, hypervigilance, nightmares, and dissociation. The patient's mood was dysphoric with low self-worth, decreased energy, appetite sleep disturbance and volition, lower back pain related to scoliosis, and fair motivation for treatment.

The patient was provided treatment with intensive services, sober supports, monitoring, and structure provided within the Partial Hospitalization Program treatment program. The patient received five days per week of services that worked on trauma recovery and substance use disorder counseling. The patient was assessed with quantitative electroencephalography and was provided neurofeedback sessions, family focused sessions, and medication management with use of Wellbutrin, gabapentin and vitamin supplements including methyl folate.

During the Partial Hospitalization Program level treatment, the patient was noted to be making steady progress, however continued to struggle with anxiety. The patient continued to struggle with feelings of sadness, loneliness, resentfulness, and social isolation. There was intermittent use of cannabis during the stay prompting the substance use disorder counseling. Treatments were continued to address the co-occurring psychiatric disturbances and efforts to facilitate family support. 

By the last weeks of Partial Hospitalization Program treatment, the patient's mental status examination showed persistently improved mood and improved insight that was judged to be fair. The patient reported feeling better and was judged to be better motivated to remain in treatment. The patient was discharged to home with their parents and recommended to continue outpatient treatment and participate in sober living. At issue is the medical necessity of Partial Hospital Program Treatment.

The requested treatment of Inpatient Mental Health Services was medically necessary for this patient. The submitted documentation reflects that the services were medically necessary and clinically appropriate regarding the structure, intensity, and duration of treatment. The patient presented with worsening symptoms of their comorbid conditions, a decline in functioning, severe trauma related symptoms and substance abuse. The patient was considered high risk for relapse due to limited coping skills per the clinical summary, deficient recovery environment as well as a history of treatment failure with lower-level services.

Moreover, the patient's psychosocial stressors complicated this case, and the Partial Hospitalization Program level care was medically necessary to provide evidence-based psychosocial therapies and treatment interventions. Sessions also served to address the patient's social environment, recovery environment and family focused sessions with the development of a safe and clinically appropriate disposition and discharge plan.