Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Major Depressive Disorder, Substance Abuse.

Treatment: Residential Mental Health services.

The insurer denied the Residential Mental Health services.

The denial was overturned.   

This is a male patient who had a history of Major Depressive Disorder, Generalized Anxiety Disorder, Attention Deficit Hyperactivity Disorder (ADHD), Opiate and Cannabis Use Disorder. He was admitted to this inpatient mental health residential treatment due to depressive symptoms, substance use issues, and behavioral issues. He reportedly had daily suicidal ideation and had multiple suicidal plans including shooting himself, jumping in front of a train, and hanging himself.  He had reports of depressed and irritable mood, poor anger and impulse control, isolation, past physical aggression, property destruction past self-injurious cutting behavior, multiple substance use including cannabis 2 grams per week and opiate pills, as well as cocaine use weekly, and he reportedly tried hallucinogens.  He reportedly had poor coping skills and poor identification of triggers, difficulty with communication and interpersonal skills, and had reports of past driving under the influence (DUI) and cocaine possession charges.  He reportedly had been in a substance residential treatment and another residential treatment the prior year. He had reported diagnoses of Major Depressive Disorder, Generalized Anxiety Disorder, Attention Deficit Hyperactivity Disorder (ADHD), Opiate and Cannabis Use Disorder. 

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. The APA Practice Guidelines for the Treatment of Patients with Suicidal Behaviors reports that patients may require more time in an inpatient setting to better assess suicide because they sometimes do not tell the truth regarding their suicidal thoughts in order to leave the facility.  This patient was considered a high risk patient due to his reports of daily suicidal ideation that worsened prior to this admission, continued suicidal thoughts, depression, limited coping skills, and he required more time in this 24 inpatient hour therapeutic residential treatment to further progress and improve more with coping skills so as not to use maladaptive ways of dealing with emotions or stressor, and he needed to better identify triggers to use and emotional dysregulation as well as behavioral issues.  He had past reports of legal issues and past reports of long stays in residential treatments and he still was struggling with significant psychiatric symptoms, behavioral issues, and multiple substances of use so the time spent in this setting was not considered enough time as he was still at risk.  

This was a high risk patient with significant psychiatric issues and substance use issues as well as behavioral issues interfering significantly with his functioning and he required a longer period of time in a 24 hour therapeutic mental health residential treatment to further progress and decrease the chances of maladaptive coping, relapse, suicide, and worsened psychiatric symptoms when not in this 24 hour setting.  

It did not appear that the health care plan acted reasonably or in the best interests of the patient then.  

The carrier's denial of coverage for continued Residential Mental Health services is overturned.  The medical necessity is substantiated.