Appeal type: Medical necessity
Decision: Overturned

Diagnosis: PTSD (post-traumatic stress disorder, Major Depressive Disorder) Generalized anxiety Disorder, Unspecified Eating Disorder, and Cannabis Use Disorder. 
Treatment: Mental Health Residential Treatment Level of Care. 

The insurer denied coverage for Mental Health Residential Treatment Level of Care. 

The denial is overturned. 

This patient was admitted to this inpatient mental health residential treatment due to post traumatic stress disorder (PTSD) trauma related symptoms, depressive symptoms, anxiety, eating disorder symptoms, and substance use, and past self-injurious behavior and multiple past suicide attempts. She reportedly had depressed mood, hopelessness, low self-esteem, guilt, anhedonia, poor appetite, past suicide ideation and multiple past suicide attempts including overdose of pills and alcohol, hanging, drowning, suffocating, and slitting wrists. She reportedly had self-injurious behavior, dangerous behavior including impulsive sexual behavior, and PTSD symptoms including flashbacks, nightmares, dissociative symptoms, shame, self-blame, as well as anxiety, worrying, panic attacks, and obsessive-compulsive symptoms. She also reportedly had eating disorder symptoms including restricting, purging, separating food, weight fixation, eating quickly, body image distortion, hiding and throwing away food, body checking, calorie counting, food rituals, and thinking about food more than 5 hours per day. She was using cannabis to get numb. She had past hospitalization and a past inpatient eating disorder residential treatment. She took Zoloft and Abilify, attended group, individual, and family therapy. She reportedly was discharged. 
  
The Milliman Care Guidelines (MCG) Residential-Behavioral Health Level of Care- Psychiatry guidelines report that one needs to have continued danger to self or others, moderately or severe psychiatric or behavioral symptoms requiring 24-hour daily treatment, or serious dysfunction in daily living. For discharge it states that there needs to be sufficient support at a lower level of care, absence of suicidal or homicidal thoughts or thoughts of harm to self or others. In this case this patient continued to have moderate psychiatric symptoms and did not have the coping skills to deal with her multiple psychiatric issues, eating disorder issues, and substance use. She was a complex patient with multiple psychiatric diagnoses including PTSD, Major Depressive Disorder, Generalized anxiety Disorder, Unspecified Eating Disorder, and Cannabis Use Disorder. She reportedly had maladaptive coping skills, poor communication, feelings of shame and guilt, multiple past suicide attempts including  overdose of pills and alcohol, hanging, drowning, suffocating, and slitting wrists, self-injurious behavior, poor insight into how her trauma and psychiatric symptoms affected her poor coping skills of self-injurious behavior and suicide attempt6s, substance use, eating disorder symptoms, sexual behavior, impulsivity, poor boundaries, difficulty dealing with parental conflict including the parental divorce, and difficulty identifying triggers to her maladaptive behaviors and cognitive distortions. She had past recent hospitalization and residential treatment for eating disorders but needed more residential treatment to try to better process and deal with trauma and PTSD symptoms, depressive symptoms, anxiety symptoms, and substance use. She had multiple psychiatric diagnoses and symptoms and required more time in a 24-hour inpatient therapeutic residential treatment to learn sustained improved coping skills to decrease dangerous and maladaptive behaviors and use health coping skills. She needed to improve her independence and self-confidence, expression of feeling, communication, better identify triggers, improve insight, boundaries, health social interactions and relations, and continue to work on decreasing eating disorder thoughts and behaviors. 

The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Suicidal Behaviors reports that patients with past suicide attempts are at high risk for suicide and this patient had multiple past serious suicide attempts by overdose of pills and alcohol, hanging, drowning, suffocating, and slitting wrists so she was considered a high risk patient for suicide and self-injury if she did not learn better coping skills while in a 24 hour therapeutic supervised and structured residential treatment setting. 

Inpatient mental health residential treatment was medically necessary. It did not appear that the health care plan acted reasonably, with good clinical judgment, or in the best interests of the patient. 

The insurer's denial of coverage for the Mental Health Residential Treatment Level of Care is overturned. Medical necessity is substantiated.