Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Anxiety.
Treatment:  Residential Mental Health Services.

The insurer denied the Residential Mental Health Services.  The denial is upheld. 

The patient is a male.  He was treated on an outpatient level of care sex addiction, substance abuse, trauma and anxiety.  His psychiatrist writes that despite medication changes and increases in therapy to twice a week, including both individual and group therapy, the patient's symptoms worsened.  He was therefore referred to a residential treatment facility.

The patient first required psychiatric treatment at a young age due to anxiety and school difficulties.  He had school-based mental health support in addition to private speech and reading therapy.  Later, he became increasingly anxious and socially debilitated with virtually no peer interactions.  He began drinking excessive amounts of scotch intermittently.  Although he had fleeting passive suicidal ideation, there was no evidence of active suicidal thoughts, plan, or intent.  Per the records, he began to display obsessive eating habits, sexual addiction, and excessive shopping as escape behaviors.  In a lengthy appeal letter, the patient's parents write that despite ongoing treatment, the patient's unresolved trauma history and subsequent addictive behaviors led to a "psychotic breakdown and feelings of complete despair." 

The patient's traumatic history is not clearly detailed in the records, but it refers to some sort of sexual abuse at a young age by a babysitter or nanny.  Despite various treatment modalities, the patient's parents and his psychiatrist concluded that the patient required an inpatient rehabilitation program to address "layers of trauma, years of severe addiction, debilitating OCD [obsessive compulsive disorder], anxiety, and moderate depressive behaviors."

At the time of admission, the patient reportedly felt shame, low self-esteem, nightmares, flashbacks, and some PTSD (posttraumatic stress disorder) symptoms.  He reportedly had sexual compulsions, but these are not detailed.  The rationale for residential treatment was that the patient had never dealt with the alleged sexual abuse or acting out.

At the time of admission, the patient was described as very thin, young-looking, somewhat effeminate, with good activity, appropriate affect, depressed mood, and anxiety.  His thoughts were logical and goal directed, with no suicidal ideation or signs of psychosis.  His admission diagnoses were major depressive disorder, recurrent, severe, without psychosis, generalized anxiety disorder, social anxiety disorder, OCD (obsessive compulsive disorder), and alcohol use disorder.  He was described as being motivated for treatment, cooperative, and willing to attend daily 12-step programming.

No, the Residential Mental Health Services were not medically necessary.

The primary motivations for treatment were social anxiety, compulsive sexual behaviors (with no evidence of victimization of others), possible substance abuse, and depression that failed to respond to outpatient treatment.  Patients with similar presentations often have difficulties responding to outpatient treatment.  This does not mean in and of itself that residential level of care is required.  For the dates of service under review, the patient was not behaviorally out of control.  He was calm, cooperative, not suicidal, not dangerous to others, and highly motivated.  Nothing in the documentation reviewed indicates that for the dates under review, 24-hour confinement in a residential center so far away from his community and his family were medically necessary or in this patient's best interest.