Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Unspecified Schizophrenia Spectrum 
 
Treatment: Continued Residential Treatment Mental Health Services 

The insurer denied the Continued Residential Treatment Mental Health Services. The denial was upheld. 

This is a female patient with a history of unspecified Schizophrenia Spectrum and other Psychotic Disorders, PTSD, and attention deficit hyperactivity disorder (ADHD). She was admitted to inpatient residential mental health treatment after being hospitalized for psychotic and mood symptoms. It was reported she had auditory, visual, tactile hallucinations, paranoia, perceptual disturbance, depressed and angry mood, posttraumatic stress disorder (PTSD) symptoms, anxiety, and feelings of shame, self-loathing, loneliness, and hopelessness. 

The medical records provided did not provide specific evidence to support that she could only be safely and effectively treated in this inpatient residential mental health treatment then or that she could not safely and effectively treated in a less restrictive setting.  The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Schizophrenia report that the least restrictive level of care for safe and effective treatment is appropriate.  It also states that patients with hallucinations, delusional thinking, disorganized thinking or behavior, suicidal or homicidal plan or intent, agitation, or aggressive behavior are candidates for inpatient treatment.  In this case the patient had improvement in her clinical condition from admission as she denied psychotic symptoms, had less reported depressive symptoms, and she denied suicidal ideation, and there were no reports of out of control behavior.  

The notes on a specified date reported that she denied psychotic symptoms, still had depressed mood but had less depression and was feeling better, had brighter affect, was more energized and forward looking, had no hallucinations or delusions, was goal directed in thought process, and she was not taking antipsychotic medication anymore.   She reportedly was taking Wellbutrin.  Notes reported that psychosis appeared to have resolved with no antipsychotic medications.  It was reported that after an increase in Wellbutrin dosage, she had significant mood benefits.  It also was reported that her current presentation was close to her baseline.  There were no reports of suicidal or homicidal ideation, self-injurious, threatening, or aggressive behavior.  The notes reported that she was moved to a step down residential treatment.  The notes on notes from reported that she was at baseline with some variability of mood.  She reportedly denied psychotic symptoms despite not taking antipsychotic medications.  She responded to the medication changes and treatment and was no longer reporting psychotic symptoms, had less reported depressive symptoms, and denied suicidal or homicidal ideation.  

The chart notes as of the day of admission did not provide enough specific evidence to support that she was still having severe psychiatric symptoms requiring 24 hour mental health residential treatment then.  As of then, the chart notes did not report specific identifiable and quantifiable treatment objectives or goals that could only be achieved in a 24 hour mental health residential treatment or that she could not be treated in a less restrictive level of care.  

It appeared that the health care plan acted reasonably and with sound medical judgment and in the best interests of the patient.  

The carrier's denial of coverage for the continued residential treatment mental health services is upheld.  The medical necessity is not substantiated.