Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Depression. 
Treatment: Residential Mental Health Treatment with 24 Hour A Day Support. 
The insurer denied the Residential Mental Health Treatment with 24 Hour A Day Support. 
The denial is upheld. 

The patient is a non-binary person who prefers female pronouns. She was admitted to a behavioral health residential treatment level of care. She was reported to have been diagnosed with bipolar disorder, attention deficit hyperactivity disorder, inattentive type, obsessive-compulsive disorder, unspecified and gender dysphoria. Other diagnoses indicated include unspecified substance use disorder, anorexia nervosa, borderline personality traits, personal history of self-harm and suicidal ideation and parent-child conflict. She was reported to have been admitted to the residential treatment level of care for persistent symptoms of depression and anxiety with intermittent thoughts of harming herself. The patient was also reported to have some intermittent undefined hallucinations. She was noted to have some obsessive thoughts and compulsive behaviors. 

The patient was noted to have a significant history of behavioral health treatment in the past. She was noted to have been admitted to an acute inpatient unit earlier last year for approximately over a month followed by residential treatment for approximately a month. The patient was reported to have been readmitted to an acute inpatient psychiatric unit from where she was discharged. Subsequently, she was reported to have been admitted to a different residential treatment program prior to her admission to the current treatment facility. 

The clinical information does not indicate that the patient had any significant ongoing behavioral health symptoms that required a 24-hour setting. She was noted to have persistent irritability, mood dysphoria and anxiety which appeared to be her baseline and did not represent a significant change. The patient was reported to have intermittent passive thoughts of wanting to harm herself. However, she was not reported to have any active and ongoing suicidal or homicidal ideations with plans or intent. There was no indication that the patient continued to be at high risk of harm to self or others. She was not reported to have any symptoms suggestive of psychosis including command hallucinations, persecutory delusions, or extreme paranoia. She was not reported to have any significant symptoms suggestive of mania or hypomania. She was not reported to have exhibited any significant and persistent agitation or aggressive behaviors. The patient was not reported to have engaged in any self-injurious behaviors recently and was not reported to have any significant urges. 

No, the continued residential treatment level of care was not found to be medically necessary. 

Based on current evidence-based medical literature, the requested service (behavioral health residential treatment level of care through discharge) was not found to be medically necessary. The clinical information provided does not indicate that the requested service was the least restrictive setting that was medically necessary or was likely to be successful in treating the patient's symptoms. 

Treatment at a residential level of care with a 24-hour structured setting is required when there are significant safety concerns that require daily monitoring, significant functional impairments related to behavioral symptoms including impairments in self-care and activities of daily living, or significant substance use affecting daily functioning (1-9). Such symptoms include persistent low mood, agitation, aggression (1, 4, 7), persistent active suicidal ideations, symptoms of psychosis or mania, and continued substance use affecting physical and emotional health. 

The clinical information reviewed indicates that the patient had no significant ongoing symptoms that required the 24-hour structured setting of a residential treatment level of care. The clinical information does not indicate that the patient had any significant ongoing behavioral health symptoms that required a 24-hour setting. She was noted to have persistent irritability, mood dysphoria and anxiety which appeared to be her baseline and did not represent a significant change. The patient was reported to have intermittent passive thoughts of wanting to harm herself. However, she was not reported to have any active and ongoing suicidal or homicidal ideations with plans or intent. There was no indication that the patient continued to be at high risk of harm to self or others. She was not reported to have any symptoms suggestive of psychosis including command hallucinations, persecutory delusions, or extreme paranoia. She was not reported to have any significant symptoms suggestive of mania or hypomania. She was not reported to have exhibited any significant and persistent agitation or aggressive behaviors. The patient was not reported to have engaged in any self-injurious behaviors recently and was not reported to have any significant urges. 

The patient was not reported to have any significant ongoing medical conditions that required interventions or monitoring. There was no indication of the patient had any significant functional impairments including age-appropriate activities of daily living or self-care that represented a change from her baseline. The patient was not reported to have any significant adverse effects from any prescribed psychotropic medications. There was no indication of the patient required any significant changes in her medication regimen throughout the rest of her stay at the residential treatment level of care. There was no indication of the patient had any significant barriers to treatment in the community including severe psychosocial stressors, lack of social support or unsafe living environment. The clinical information reviewed indicates that the patient may have been treated safely in a less restrictive setting and lower level of care such as a day treatment program. 

Yes, the health plan did act reasonably, with sound medical judgment, and in the best interest of the patient. 

Clinical information reviewed does not indicate that the patient had any significant ongoing behavioral health symptoms that required a 24-hour structured setting with medical and nursing care available. The patient was noted to have intermittent episodes of irritability, mood dysphoria and anxiety which appeared to be her baseline and did not represent a significant change. There was no indication that the patient continued to have active suicidal or homicidal thoughts or urges to engage in self-injurious behaviors. There was no indication of the patient continued to be at risk of harm to herself or others outside of a 24-hour structured setting. She was not reported to have any symptoms suggestive of mania or psychosis. The patient was not reported to have any significant ongoing medical conditions that required interventions or monitoring. She was not reported to have any significant functional impairments including age-appropriate activities of daily living or self-care that represented a change from her baseline. There was no indication of the patient had any significant barriers to continuing treatment in the community. The patient may have been treated safely and effectively outside of the residential treatment setting. Therefore, the health plan was noted to have acted reasonably, with sound medical judgment and in the best interest of the patient.