Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Major Depressive Disorder-Severe-Recurrent.
Treatment:  Continued Mental Health Services at the Partial Hospitalization Level of Care.

The insurer denied coverage for the continued Mental Health Services at the Partial Hospitalization Level of Care.  The denial is overturned.

This is a female patient, who was admitted to the inpatient rehabilitation facility, due to depressive symptoms including suicidal ideation, depressed mood, lack of energy and motivation, sleeping problems, poor concentration, post-traumatic stress disorder (PTSD) symptoms including flashbacks, and she had a history of self-injurious behavior.  The patient had past reported suicide attempts including overdose.  The patient had reports of having many past psychiatric facility treatments.  The patient reportedly had a history of alcohol, opiate, amphetamine, and cannabis use.  The patient had reported diagnoses of Major Depressive Disorder-Severe-Recurrent, PTSD, Opiate, Alcohol, Amphetamine, and Cannabis Use Disorder.  The patient was admitted and was treated with Seroquel, Wellbutrin, gabapentin, Lexapro, Prazosin, and clonidine as needed.  The patient reportedly attended group and individual therapy.  The patient was discharged from partial hospital program treatment to intensive outpatient program treatment.

The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Major Depressive Disorders reports that the least restrictive level of care for safe and effective treatment is appropriate.  In this case, this patient had reports of depression, hopelessness, poor energy and concentration, had a positive urine toxicology, and she reportedly was restricting her food intake still during the denial period, so she was still reporting significant symptoms requiring at least this partial hospital program level of treatment then.  Notes during the denial period reported that the patient had a positive toxicology for buprenorphine; she needed to work on self-soothing skills, and she reportedly was restricting food intake.  The patient reportedly had disorganized eating patterns, had a desire to lose weight, was disengaged, depressed in mood, hopelessness, unwilling to make changes, fatigued, weak, had poor concentration, and needed to work on distress tolerance.  The patient reportedly was stepped down to intensive outpatient program treatment. 

As per the American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Suicidal Behaviors, patients with past suicide attempts are at increased risk for suicide.  This was an at-risk patient, who had a past suicide attempt by overdose, past self-injurious behavior by cutting, scratching, and burning self, and she had reports of many past psychiatric facility treatments, and who still reported symptoms of depression and hopelessness while restricting food intake.  The patient also had a positive toxicology screen and significant past alcohol and substance use history. 

Based on the review of the medical record and the literature, continued Mental Health Services at the Partial Hospitalization Level of Care was medically necessary for this patient. 

The health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient. 

Based on the above, the medical necessity for the continued Mental Health Services at the Partial Hospitalization Level of Care is substantiated.  The insurer's denial should be overturned.