Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Major depressive disorder, generalized anxiety disorder, and alcohol abuse. 
Treatment: Residential mental health admission. 

The insurer denied coverage for residential mental health admission. 

The denial is overturned. 

This case involves a female diagnosed with Major depressive disorder, generalized anxiety disorder, and alcohol abuse. 

The patient was admitted to residential treatment due to depressive symptoms, suicidal thoughts, anxiety, alcohol use, eating disorder symptoms, past suicide attempts and self-injurious behavior, and trauma related symptoms. She reportedly had depressed mood, suicidal thoughts, hopelessness, worthlessness, shame, concentration problems, sleeping problems, crying, decreased interest, pleasure and energy, amotivation, self-blame, high anxiety, impulsive behaviors, victimization of rape at school, 3 past suicide attempts including an overdose with alcohol and opiates, an overdose with Benadryl and an overdose with Klonopin. She reportedly was restricting fluids and food intake and had cognitive distortions. She reportedly had impairment in functioning as she attended class intoxicated or missed class due to alcohol sue and psychiatric symptoms. She also reportedly had family conflict as her father reportedly came back from military deployment with post-traumatic stress disorder (PTSD) and traumatic brain injury (TBI). She reportedly was drinking 3-4 whiskey drinks daily. She reportedly had a past psychiatric hospitalization. She reportedly took Abilify and Bupropion, attended individual and group therapy, family therapy, dialectical behavioral therapy (DBT), cognitive behavioral therapy (CBT), yoga, adventure and equine therapy, music therapy, and horticulture. She reportedly eventually improved enough for discharge with step down to a partial hospitalization program (PHP). 
  
The insurer denied coverage for continued inpatient behavioral health residential treatment as not medically necessary treatment. They stated that she was no longer at risk of serious harm to self, did not require 24-hour residential treatment, and they recommended a less restrictive level of care. 
  
This reviewer disagrees with the decision to deny coverage for continued inpatient behavioral health residential treatment as the medical records provided enough specific evidence to support that she required that level of care. The Milliman Care Guideline (MCG) Residential-Behavioral Health Level of Care- adult guidelines report that one needs to have continued danger to self or others, 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 this patient continued to have moderate psychiatric symptoms and did not have the coping skills to deal with her multiple psychiatric issues, eating disorder issues, and substance use. She was a complex patient with multiple psychiatric diagnoses including Major Depressive Disorder, generalized anxiety disorder, and alcohol abuse and had eating disorder symptoms and trauma issues who continued to report suicidal thoughts and limited coping skills in dealing with her psychiatric symptoms and still had urges to drink. She required more time in this therapeutic structured and supervised residential treatment to learn more coping skills so as not to act in maladaptive ways in dealing with her psychiatric symptoms. 

Notes reported increased suicidal ideation and that she was struggling with reasons to live and not ready to leave this facility yet. Notes reported that she still struggled with suicidal ideation multiple times per day, had urges to self-harm, depression still, and with her 3 past suicide attempts and history of impulsive behavior, she was considered still at risk for suicide and alcohol relapse. Notes show that she was doing Eye Movement Desensitization and Reprocessing (EMDR) and reported that she was struggling with shame, had suicidal ideation, cravings and urges, impulse control problems, racing thoughts, and somatic distortions. Notes reported high anxiety and rapid speech. It also reported that she was at great risk for relapse due to rigid and intrusive thinking, and she still had impulse control issues as well as cravings and urges. She reportedly had shame which increased suicidal thoughts, and also had depression still. She reportedly was struggling to develop and implement effective coping skills that allow normal interaction with others without irrational fears or intrusive thoughts controlling behavior. Notes reported that she still had moderate depression and anxiety, suicidal thoughts, and was struggling to reestablish hope. Notes reported cravings, and she was working on depression and anxiety treatment, independent living skills, interpersonal effectiveness, and she had cravings and working on self-acceptance and hope but had less overall depression and anxiety. 

She reportedly was discharged with referral to PHP treatment. She had multiple psychiatric diagnoses and symptoms and required more time in a 24-hour inpatient therapeutic residential treatment to learn sustained improved coping skills to decrease dangerous and maladaptive behaviors and use health coping skills. Also, 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 3 past serious suicide attempts by overdose of pills, alcohol, and opiates so she was considered a high-risk patient for suicide and self-injury if she did not learn better coping skills while in a 24 hour therapeutic supervised and structured residential treatment setting. This was a high risk patient with 3 past suicide attempts, self-injurious behavior, moderate depressive and anxiety symptoms, trauma related issues, eating disorder symptoms, alcohol abuse, poor coping skills, impairment in functioning who still had reports of moderate psychiatric symptoms, suicidal thoughts, and cravings during the denial period  who required more time in this therapeutic structured and supervised residential treatment to learn more coping skills so as not to act in maladaptive ways in dealing with her psychiatric symptoms. As a result, the recommendation is to reverse the previous decision and approve coverage for inpatient mental health residential treatment. 

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 the residential mental health admission is overturned. Medical Necessity is substantiated.