Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Major Depressive Disorder

Treatment: psychiatric Residential Treatment Center (RTC)

The insurer denied coverage for psychiatric Residential Treatment Center (RTC)

The denial is upheld 


This is an older teenager with a history of Major Depressive Disorder (Moderate-recurrent), Generalized Anxiety Disorder, attention deficit hyperactivity disorder (ADHD), post-traumatic stress disorder (PTSD), Unspecified Eating Disorder and Borderline Personality Disorder. The patient denied cannabis use for 1-2 months. The patient had received past partial hospital program (PHP) treatment for 3 months previously. The patient was reported to have had a past eating disorder residential treatment stay for 2 months previously and had received prior outpatient treatment. The patient was receiving services in the mental health residential treatment setting due to mood, anxiety, and behavioral symptoms. According to the psychiatric evaluation, the patient had depressive symptoms including sad and irritable mood, crying, isolation, loss of interest, low self-esteem, anxiety symptoms, fidgeting, and PTSD symptoms after witnessing violent acts in a past residential treatment center. The patient had past physical altercations with their mother in which police were called, impulsivity, school refusal, staying out past curfew, sneaking out of the house, stealing, oppositional behavior, past self-injurious behavior by scratching self, and past restricting and purging behaviors. It was reported that the patient had no current eating disorder symptoms. The patient had stopped Fluoxetine and Hydroxyzine, stating that they were ineffective. The patient was attending group therapy including dialectical behavioral therapy (DBT) skills which included core mindfulness, interpersonal effectiveness, distress tolerance, and emotional regulation.

The Milliman Care Guideline (MCG) Residential-Behavioral Health Level of Care 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. 

In this case, the patient had reported improvement in clinical symptoms from the psychiatric evaluation. Notes reported that the patient was not experiencing anxiety or depressive symptoms, had a stable emotional state, denied suicidal or homicidal ideation, or hallucinations, and there were no imminent safety concerns. The patient also reportedly was not taking psychotropic medication. Notes reported that the patient was mentally stable and hopeful and was doing outdoor activities to challenge development and enhance their self-concept and self-esteem.  Notes reported that the patient was anxious and cooperative, understood unhealthy behaviors and potential consequences. The patient's insight was improving. There were reports of euthymic mood, no hallucinations, suicidal or homicidal ideation, and good concentration. The patient denied cravings/urges. The patient had no reports of maladaptive eating behaviors. 

The medical records did not provide enough specific evidence that the patient could only be effectively treated in a 24 hour inpatient therapeutic mental health residential treatment or that the patient could not be treated in a less restrictive level of care. There were no reports of severe depressive symptoms, emotional dysregulation, aggressive or self-injurious behavior, suicidal ideation, plan, or intent or evidence of danger to self or others requiring 24 hour inpatient treatment, or reports of acute psychotic symptoms rendering them unable to care for basic needs. 

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for psychiatric Residential Treatment Center (RTC) is not substantiated.