Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Anxiety; Depression; Eating disorder; Borderline personality disorder
Treatment: Residential mental health services 
The insurer denied the Residential mental health services.
The denial is upheld. 

The patient is a female, for whom this was one of multiple psychiatric treatment episodes. She has a history of eating disorder and self-harm, including cutting derogatory words into her skin. She was transferred to the residential program in Utah following a lengthy acute inpatient stay elsewhere. Her diagnoses included unspecified depressive disorder, unspecified anxiety disorder, borderline personality disorder and unspecified eating disorder. During the acute inpatient stay typical behaviors included scratching herself with a paperclip or a fork and smearing blood on the walls.
 
The patient reportedly had been purging daily and was refusing food and water. She stated that she had a desire to die and that she would like to escape the program and run into the woods to harm herself. Her complaints included poor body image, self-loathing and a history of being bullied. She felt left behind in her family due to having two special-needs brothers, and believed that no one cared about her. Although the patient reported passive suicidal thoughts, there was no credible evidence of intent, plan, or means. Her weight was within normal limits, and there were no acute medical conditions or laboratory abnormalities. She was not orthostatic. She was not violent.

At the time of her transfer from the acute inpatient facility to the current residential facility, the patient was future oriented and said she wanted to go home and go to college. She admitted to depression and anxiety with chronic passive suicidal ideation. 

The patient's medications included Depakote, Abilify, Zyprexa, Clozaril, and Latuda, although not concurrently.

Per the medical records, the patient was provided group therapy for two days every couple of weeks. The records reflect individual therapy, generally on a weekly basis, but psychiatric appointments were by telemedicine rather than in person. There is no evidence that the provider was on site for any of the appointments, and it should be noted that this treatment episode occurred prior to the COVID-19 pandemic. Some of the treatments that were provided include EMDR (eye movement desensitization and reprocessing) and Clozaril. Other treatment modalities included games, puzzles, cards, and spending time with a horse. 

Many of the records consist of simple night shift time logs. Others are self-harm checklists, which were generally negative. Others were narrative descriptions of telephone conversations between staff and the patient's parents, who were at times at odds over the treatment plan.

The patient's health plan denied coverage on the basis of, "The care provided by this facility was not consistent with level of care guidelines as the medical records demonstrate very few groups and individual therapy sessions. In addition, at the time of your daughter's admission, the facility could not be authorized for services due to the service components for medical oversight not being consistent with guidelines for mental health residential setting."

No, the Residential mental health services  was not medically necessary. 

This patient's problems were consistent with her Axis II Cluster B (borderline personality disorder) diagnosis. Although the patient had at times engaged in parasuicidal behaviors, there was no documented evidence of true, imminent danger to self or others. While she also reportedly had an eating disorder, her physical and laboratory states were unremarkable. Finally, as noted by the health plan, the patient's care as documented in the records reviewed was far below generally accepted standards. Nothing in the documentation reviewed indicates that this patient could not have been treated safely and more appropriately in a less intensive community setting with strong, face to face parental involvement.