Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Depression, anxiety, and impulsivity
Treatment: Inpatient mental health residential treatment
The insurer denied coverage for inpatient mental health residential treatment
 The denial is upheld.

This patient reportedly was admitted to this inpatient mental health residential treatment due to depressive and anxiety symptoms and impulsivity. She reportedly had a depressed mood, decreased interest, suicidal thoughts, hopelessness, guilt, tearfulness, excessive worrying, poor eating patterns including binging, self-harm behaviors, poor impulse control, poor insight and judgment, mood swings, and a recent past suicide attempt. She reportedly had a family history of depression. She reportedly had a history of panic attacks and crying spells. She reportedly took Lithium and Effexor. She reportedly attended individual, group, and family therapy. 

The medical records provided did not have enough specific evidence to support that she required 24-hour inpatient mental health residential treatment as of then. The MCG (Milliman Care Guidelines) Acute Behavioral Health Level of Care-Child and Adolescent Residential Treatment medical necessity guidelines report that one needs to have continued danger to self or others in the form of auditory hallucinations contributing to suicide or serious harm to self, paranoid delusions or auditory hallucinations contributing to the risk of homicide or serious harm to others or persistent thoughts of suicide or serious harm to self or homicide or serious harm to others that cannot adequately be monitored at a lower level of care. It also states that one has moderately or severe psychiatric or behavioral symptoms requiring 24-hour daily treatment or serious dysfunction in daily living. For discharge it states that there needs to be sufficient support at a lower level of care, absence of suicidal or homicidal thoughts or thoughts of harm to self or others. In this case chart notes reported that this patient denied suicidal or homicidal ideation, and had no hallucinations or delusions, had linear thought process, denied self-harm urges, and was feeling well with smoother emotional regulation. She reported that the Effexor was okay, and she was taking Lithium with some reported side effects including increased thirst and urination. It was reported that her sleep was good. There were no further specific reports of suicidal ideation, plan, or intent, severe eating disorder behavior, psychotic symptoms, self-injurious or aggressive behavior, or severely agitated behavior. There were no medical records for review that provided enough specific evidence to support that she only required 24-hour inpatient residential treatment or that she could not be treated in a less restrictive level of care then. There were no medical records reporting suicidal or homicidal ideation, plan, or intent, psychotic symptoms, self-injurious, aggressive, threatening, or severely agitated behavior, substance use, manic episodes, severe depression, or inability
to care for her basic needs. There were no reports of specific reported identifiable and quantifiable treatment goals that could only be achieved in a 24-hour residential treatment setting or that could not be achieved in a less restrictive setting or specific evidence that she was still considered a danger to self or others and had no reports in the medical records provided that she had significant behavioral or mood symptoms requiring 24 hour treatment. It appeared that the health care plan acted reasonably and with sound medical judgment. 

The insurer's denial of coverage for continued residential mental health treatment services is upheld. Medical Necessity is not substantiated.