Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Major Depressive Disorder

Treatment: residential behavioral health level of care, adult

The insurer denied coverage for residential behavioral health level of care, adult

The denial is overturned.

This patient was admitted to this inpatient mental health residential treatment after being admitted to the crisis center. She reportedly was involved in a physical altercation with her mother an kicked out of the house and charged with a misdemeanor domestic assault and was incarcerated over that weekend. She reportedly had depressive symptoms including depressed mood, suicidal ideation and plans to hurt self, hopelessness, decreased interest and pleasure, sleeping and appetite problems, concentration problems, and was drinking alcohol to numb herself, had post-traumatic stress disorder (PTSD) symptoms as she was the reported victim of assault, had worthlessness, and low self-esteem. She reportedly had emotional dysregulation and poor coping skills. She reportedly had multiple past suicide attempts by overdose resulting in psychiatric hospitalizations. She had diagnoses of Major Depressive Disorder, PTSD, Generalized Anxiety Disorder, Borderline Personality Disorder, Alcohol Use Disorder, and attention deficit hyperactivity disorder (ADHD). She reportedly was unemployed and homeless. She reportedly took Venlafaxine and Trazodone, attended group and individual therapy. It was reported that she was discharged and transferred to another inpatient residential treatment for further inpatient therapeutic residential treatment.
    
The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Major Depressive Disorders reports that the least restrictive level of care for safe and effective treatment is appropriate. The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Suicidal Behaviors reports that patients with past suicide attempts are at high risk for suicide and this patient had 2 past suicide attempts by overdose resulting in hospitalizations. She was a high-risk patient with poor coping skills and poor insight with multiple psychiatric problems and conditions including depression, anxiety, PTSD, ADHD, poor interpersonal and poor coping skills, emotional dysregulation, multiple past suicide attempts by overdose, and increased alcohol use. She reportedly continued to exhibit poor coping skills and lack of responsibility as she did not learn and sustain the necessary coping skills to function outside of a 24-hour inpatient residential treatment setting. Also, the InterQual 2020 Psychiatry Mental Health residential treatment guidelines reports that criteria are still met if one still has psychiatric or behavioral symptoms that put the patient at high risk for hospitalization if not in this 24 hour treatment, that they still have psychiatric or behavioral symptoms that are improving or expected to improve but they are not clinically stable yet, or have persistent symptoms that are unable to be managed without this intensity of services. It also states that one has symptoms including disorganized thinking or behavior, hallucinations, angry outbursts, assaultive behavior, delinquent acts, poor impulse control, psychomotor agitation, sexually inappropriate or high-risk behavior, suicidal ideation, or threatening behavior requiring 24 hour treatment. 

In this case, this patient did have continued reported psychiatric symptoms that would put her at high risk for harm to self if not in this 24 hour treatment and she still had psychiatric and behavioral symptoms that were improving or expected to improve but were not clinically stable yet, and she reportedly required continued 24 hour residential treatment to learn better coping skills, better regulate emotions, better problem solve, improve insight, better deal with trauma issues so as to decrease depressive and anxiety symptoms and decrease the risk of another suicide attempt as well as addressing her increased alcohol use as self-medication to these symptoms. She still presented as a high risk for hospitalization if not in a 24-hour residential treatment setting and was transferred to another inpatient residential treatment setting. She required this 24-hour therapeutic mental health residential treatment including the denial days. This was a complex and high-risk patient with multiple psychiatric issues and an alcohol use problem who had past suicide attempts by overdose, so she was considered high risk and in need of improving coping skills and taking responsibility for her behaviors and actions. 

Inpatient mental health residential treatment was medically necessary. 

The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for residential behavioral health level of care, adult is overturned. Medical necessity is substantiated.