Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Mental Health. 
Treatment: Mental Health Residential. 
The insurer denied residential mental health services. 
The denial is partially overturned.

The patient is a female with a history of obsessive-compulsive disorder and co-morbid major depressive disorder associated with chronic suicidal ideation with plan and severe symptoms of anxiety and functional impairments. She has co-occurring alcohol use disorder with a binge pattern of use; she has engaged in high-risk behaviors when using alcohol and due to impulsivity. Additionally, the patient has an unspecified personality disorder with cluster B and other personality traits that are maladaptive. She was referred and admitted for residential psychiatric services after failing to respond to ongoing treatment in the community including a past history of multiple psychiatric hospitalizations and suicidal behavior. Despite intensive treatments with varying psychiatric services, the patient continued to have severe symptoms of anxiety, compulsive behaviors/rituals and intrusive thoughts; and, she had a significant decline in functioning such that he was unable to work, or effectively do basic self-care, spending excessive time with compulsive rituals associated with isolation and depressive symptoms. She had a history of self-harming with cutting and hitting self and persistent suicidal thoughts with a past history of suicide attempt putting her at high risk for suicide. The subject under review is the medical necessity for the residential level of care. 

The health plan's determination is upheld in part. 

Part of the patient's continued residential level treatment is reasonable and in the best interest of the patient; she continued to display severe symptoms of obsessive compulsive disorder (OCD) and associated symptoms of depression in the context of a diagnosis of recurrent and severe major depressive disorder with past suicide attempt and persistent suicidal ideation. And, the patient had presented with significant functional impairments, as well as problems with emotional regulation reflected in her self-harming behaviors, distress problems, interpersonal functioning problems and continued impairment of functioning that had previously deteriorated to the point that she was unable to benefit from treatment at lower levels of care. During this time the patient had not made enough progress in these treatment domains or with regard to these clinical features to warrant a step down to lower level services. Step down would not have been clinically appropriate until the patient was fully engaged in treatment and showing definitive improvements. Thus, the patient warranted the continued intensity of services, structure, and ongoing monitoring of a residential program for part of the time period reviewed.
However, for the remainder of the time, the patient was doing better clinically with improved mood, diminished anxiety and gained insight, as well as improved functioning that included socialization with peers and involvement with the therapeutic interventions. The patient was doing well with daily functioning and was showing successful interactions with staff and other patients and showed cooperation with staff and compliance with treatment. Thus, the patient could have been safely and effectively managed with lower level services, for the remainder of the time.