Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Major depressive disorder.
Treatment:  Partial hospitalization for mental health services.

The insurer denied coverage for partial hospitalization for mental health services.  The denial is overturned.

This is a patient with a past medical history of major depressive disorder, obsessive compulsive disorder (OCD), body dysmorphic disorder, and autism spectrum disorder (ASD), admitted to a mental health partial hospital program (PHP) as a transition from a residential treatment. The patient had depressive symptoms, obsessive compulsive symptoms, body dysmorphic thoughts, social delays, emotional dysregulation, and difficulty with coping skills. The patient also had past outpatient mental health treatments that included dialectical behavioral therapy (DBT) treatments. The patient had multiple services in PHP including group therapies, psychoeducation, social skills training, and exposure response prevention. 

The reviewer disagrees with the decision, as this was a complex patient with multiple comorbid psychiatric symptoms and diagnoses, with limited functioning. The InterQual Behavioral Health Child Adolescent Psychiatry Partial Hospitalization medical necessity criteria are met if patients still have functional impairment and significant psychiatric symptoms that include behavioral, mood, psychotic symptoms, or if treatment is not expected to be safe in a less restrictive level of care. It also states that criteria are met if symptoms are improving and expected to improve, but the patient is not yet clinically stable in a less restrictive level of care, or symptoms are worsening. There is substantial evidence that the patient was a potential danger to self or others.

This patient continued to have rigid thinking, poor insight and judgment and coping skills, depressive symptoms, body dysmorphic thinking, obsessive compulsive symptoms, perseverative thinking, motivation issues, and had maladaptive thinking and behaviors. This patient was originally in a psychiatric hospital, then residential treatment, and finally, a partial hospital program treatment which is an appropriate transition and the next least restrictive level of care. The American Academy of Child and Adolescent Pediatrics (AACAP) reports that the least restrictive level of care for safe and effective treatment is appropriate and that the decision for level of care will depend primarily on level of function and safety to self and others. In this case, the patient still had reports of deficits in function. 

This patient had exposure response prevention treatment but needed more time to challenge rigid thinking and obsessions. Notes reported that the patient needed additional neuropsychiatric consultation as symptoms and behaviors were consistent with ASD and still needed work on self-regulation, planning, and organization. When the patient was discharged, it was reported that the recommendation was to continue treatment in the PHP and that the patient had not achieved therapeutic goals. The medical records provided enough specific evidence to support that this patient had multiple comorbid psychiatric symptoms and diagnoses and had limited functioning. As a result, there was a potential risk of harm to self or others if coping skills and rigid maladaptive thinking did not decrease. 

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment, and in the best interest of the patient. The medical necessity for partial hospitalization for mental health services is substantiated.