Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Depression
Treatment: Inpatient admission
The Residential rehabilitation was medically necessary for this patient.

The patient's admission, comprehensive evaluation and mental health residential treatment and substance use disorder rehabilitation services could not have been safely or effectively provided at a lower level of care for the time frame under review. The patient was functionally impaired with severe symptoms including ongoing risk for suicidal or self-destructive behavior. He had emotional/psychiatric co-morbidity with active symptoms, and had not responded to clinically appropriate treatments with lower level services prior to the time frame under review that had culminated in high risk behaviors including gambling, severe substance use disorder and treatment failure or treatment refractory depression with referral for residential level treatment. Indeed, at the time of admission and throughout the stay, the patient's symptoms of mood disturbance and anxiety-related  symptoms persisted with continued need for the intensity, structure and monitoring of a residential level setting.

Not until the last two days of the stay had the patient made the progress, demonstrated the insight, and achieved a level of emotional stability and symptom relief that he was capable of benefitting from and continuing treatment in a less structured and less intense treatment setting with planning for continuing and intensive treatment. The last two days of the stay provided for the development of a safe and clinically appropriate discharge plan and disposition. Thus, medical necessity is met in this case scenario, and coverage for the requested benefit is reasonable and consistent with prevailing standards of medical practice, as the patient remained symptomatic, at imminent risk for harm, and in need of the structure, monitoring, intensity and extent/duration of residential services provided.

This answer is consistent with prevailing standards of professional practice, published practice guidelines, and the scientific literature, referenced below, including NY State instruction for this review and the application of NY State OASAS LOCADTR Guidelines, also referenced below.

The continued Mental Health and Substance Use Disorder Treatment was not amenable to treatment at a lower level of care, and therefore should be covered. The patient continued to display active symptoms of the mood disorder with risk factors that did require the continued structure and intensity of services of a residential setting including safety precautions while participating in intensive, evidence-based treatments for his psychiatric disorder together with treatment targeting the addictions. There are severe psychiatric symptoms with functional impairment in this case complicated by psychosocial factors that had failed to respond to lower level treatments, and that had resulted in safety concerns with suicidal risk. Thus, the patient required the continued and ongoing residential level services and intensive treatment, as requested, as medical necessity was met for the requested Residential Mental Health Treatment for the time interval under review. This answer is consistent with NY State instruction for this review including the application of NY State OASAS LOCADTR 3.0 Guidelines and with prevailing standards of medical practice in keeping with the guidelines and scientific literature, referenced below.