Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Problems with Mood, Anxiety and Coping Skills; PTSD (posttraumatic stress disorder).
Treatment: Inpatient Mental Health Services.
The insurer denied the inpatient mental health services.
The health plans determination is overturned.

The patient is a male who was referred to residential treatment by his outpatient clinician. The patient had severe symptoms of treatment refractory mood and trauma related disorder, comorbid attention deficit hyperactivity disorder (ADHD)-inattentive type, and co-occurring substance use disorders. The patient had become increasingly anxious and depressed precipitated by a previous cycling crash with injury and a recrudescence of symptoms related to childhood traumas resulting in deterioration in functioning despite several treatment episodes and medication trials. He had received ongoing psychotherapy which had failed to produce a response or remission. He was diagnosed with bipolar mood disorder with intermittent psychotic features, posttraumatic stress disorder (PTSD) with dissociation, ADHD, and co-occurring substance use disorder with alcohol and cannabis class substances, as well as a history of recreational use of hallucinogens and stimulants. The patient presented with a clinical course that included worsening symptoms of comorbid psychiatric conditions and severe substance use disorder with unemployment, social isolation, and the inability to care for self. Thus, he was referred for residential treatment to provide for more intensive treatment in order to address the mood disturbance, anxiety and trauma-related problems together with deficient coping skills and co-occurring substance use.

During his continued stay, the patient became increasingly cooperative and receptive with treatment and social with peers with continued mood disturbance, affective instability and sleep disturbance. He received motivational interviewing and enhancement with regard to the substance use disorder, and dynamic and behavioral therapy with focus on mindfulness and distress tolerance, as well as emotional regulation, and trauma recovery. He denied active suicidal ideation, plan or intent during this time interval, and had no evidence for passive suicidal ideation or risk. The patient's insight, judgment and impulse control remained fair.

The patient required the admission and the continued inpatient residential level care in order to remain safe and for the administration of treatment for his psychiatric disturbances while conducting an evaluation, and while observing his functioning with the resumption/adjustment of clinically appropriate medications to address the mood disturbance and stabilize mood while implementing evidence-based treatments to address the comorbid conditions, PTSD and the co-occurring substance use disorder. The clinical course is complicated by his past history of complex medical trauma with a brain injury. Additionally, the treatment team was planning for a step down with intensive treatment targeting mood with trauma recovery in order to achieve a safe and clinically appropriate disposition and discharge plan that would also allow for co-occurring substance use disorders.
 
The continued structure and monitoring and intensity of services with residential level treatment is warranted for the patient in order to effectively address the patient's risk of relapse, allow the patient to begin learning adequate coping skills, and to continue treatment for the co-occurring mood and trauma-related disorders, as well as the work needed to develop a solid plan for step down with sober supports.

The continued stay is medically necessary in order to monitor the response to medications, to assure that the patient will have a sustained response to treatment, and to continue to address the risk of related to severe symptoms of bipolar mood disorder and PTSD.