Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Mental Health. 
Treatment: Mental Health Inpatient. 
The insurer denied residential mental health treatment. 
The denial was overturned in whole. 

The patient is a male diagnosed with post-traumatic stress disorder (PTSD), Intermittent explosive disorder and parent-child relational problem. The patient also had history attention deficit hyperactivity disorder (ADHD). The patient has been inpatient consistently. The patient has history of aggression. The patient was not homicidal or psychotic on admission. There were no acute medical concerns. The patient has no issues with sleep or appetite. The patient denied having self-injurious behaviors. The patient is medicated with Adderall 30 milligrams (mg) every (q) day, Seroquel 200mg q day, Sertraline 100mg q day. There was no plan to change medication doses. The patient had been inpatient prior to admission. On admission, the patient had some fleeting suicidal ideation rated as a 1/10. Prior to admission, the patient has some oppositional behaviors, hit the wall when upset and had some scratching behaviors. The patient did not require medical attention. 

Prior to inpatient the patient had assaulted mother with physical aggression about 2 months prior to admission. The patient has also been verbally aggressive. The patient has history of multiple inpatient admissions. He has been in a group home due to aggression with mom. The patient has a history of having an argument with father and police were involved. Father has a restraining order. The patient is noted to be oppositional and his mother does not feel safe with him. The patient punched a wall about 2 weeks prior to admission. Father is noted to be "bipolar" and there is history of the patient witnessing domestic violence between parents. The patient has experimented with drugs in the past, last use 6 months prior to admission. 

Per the appeal letter, the patient was highly reactive, had non-compliance with programming and repeatedly found sharp objects to self-harm. The injuries worsened over time in Residential Treatment Center (RTC) due to deeper self-injury. In one example, the patient got a metal object from a binder and the staff had to sit with him for 3 hours to process until he gave it up. The patient had the object in his mouth and a level 4 hold needed to occur for the patient to hand it over. At the time of the patient's time, the patient reported he swallowed four staples. It is unknown when these two events occurred. 

The subject under review is the medical necessity for the residential treatment care. 

The residential mental health treatment was medically necessary for this patient. Given the information provided for the dates of service under review, which was shortly after admission following a long inpatient admission, the patient was significantly mood labile, oppositional, engaging in frequent self-harm, swallowing metal objects and punching walls. The patient endorsed intermittent suicidal ideation with plans when he was highly emotionally dysregulated. The patient required staff intervention frequently when dysregulated in order to calm down. There is no indication the patient could have been safely managed in a less restrictive environment due to danger to self or others during this time. Therefore, the previous denial should be overturned in full.