Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Major Depressive Disorder, recurrent, severe, Generalized Anxiety Disorder, and Cluster B Personality Disorder. 
Treatment: Continued Residential Mental Health Services. 

The insurer denied the Continued Residential Mental Health Services. 
The denial is overturned. 

The patient is a female. She was admitted to a residential treatment center for the treatment of Major Depressive Disorder, recurrent, severe, Generalized Anxiety Disorder, and Cluster B Personality Disorder. The patient's parents wrote letters of appeal. Her history of symptoms and treatments are reported. They state that her treatment at Solstice is saving her life. Prior to admission earlier in the year, she ran into the road and almost killed herself.  Medical records indicate that the patient's inpatient admission was after she ingested 30 to 40 Motrin and Aleve with the intent to commit suicide. She was regretful that the attempt was not successful. She was discharged to a PHP (partial hospitalization program). A counselor writes an email to the patient's parents stating that her level of distress and fluctuating commitment to safety is very significant and she would like to look into programs such as residential, wilderness or therapeutic boarding schools. 

Other hospital records indicate that the patient is seen for worsening suicidal ideation with a plan and is admitted inpatient. A residential program records indicate admission. The patient is diagnosed with Generalized Anxiety Disorder with panic attacks, and Major Depressive Disorder, recurrent, severe. On discharge she is noted to have made gains but demonstrated ongoing difficulty accessing her emotional regulation skills. She struggles with social skills and has a tendency to become overwhelmed by stress. She has pervasive urges to self-harm. She requires a 24-hour clinical milieu and structure. A psychologist conducted a psychological evaluation. The patient has had four inpatient and one PHP (partial hospitalization program) admissions since and has been seen in outpatient therapy and psychiatric medication management. She is diagnosed with Major Depressive Disorder and Generalized Anxiety Disorder. Continued care in a therapeutic/residential setting was recommended. 

Facility records indicate on admission that the patient is transitioning from a wilderness program where she was admitted after a dramatic decline in behavioral and emotional regulation. In that program she was on and off safety for self-harm and tried to run at one point. She would become dehydrated to get attention. Her parents report that she has had depression for a couple of years prior, with suicidal ideation with occasional plans, lack of motivation, insomnia, isolation and poor self-care. She was hospitalized and was in a PHP (partial hospitalization program). She was rehospitalized. She was then sent to wilderness therapy. Unless otherwise indicated, records describe the patient engaging appropriately in treatment. 

At the wilderness therapy program, the patient is put on safety for self-harm with a staple. She stated that she may need to go inpatient because she is not safe and does not trust herself. She had very low water intake and may be sent to the ER (emergency room) for rehydration. She says she thinks about dying all the time. The patient reported a plan to run into traffic to kill herself. She states that she is actively making plans and efforts to kill herself. She stateed that she is seriously contemplating suicide and is very anxious. She becomes agitated and reports suicidal ideation. She presented as highly dysregulated. She eventually had gone for two weeks without acting out. The following month she is seen for urination and incontinence. It is noted that she has not been hydrating sufficiently. She had continued to struggle with physical complaints. Her therapist says she is doing better in therapy. 

A month later, the patient has been refusing to go to bed or go with the team and has been making suicidal gestures. She has struggled since coming back from a home visit. She became dysregulated, and she ran out of the campus and into the street where a car swerved out of her way. She has been on suicide precautions. She reported ongoing suicidal ideation but brighter affect. She complains of depression and is focused on her body image. She presents as emotionally reactive and upset, complaining about her team, saying that she is finding it upsetting to the point of her entertaining suicidal thinking. She is responsive to treatment efforts but is highly reactive. 

The patient had been diagnosed with polycystic ovarian syndrome two months into admission. She also has trench foot and incontinence. She has gained 40 pounds in the past six months. She is doing well with an increase in Lamictal. Abilify will continue to be titrated down. She was noted to take a more measured approach to her medical concerns, demonstrating concern but with more proportion. She was seen by a doctor for a fungal infection on her foot, excessive sweating and possible asthma. Her Abilify is decreased. She was noted to be demonstrating increased stability. A few days later, she is dysregulated in a family meeting regarding some medical issues. She is tearful and complains that she is tired of not knowing what is going on. Her parents are empathic, and she takes comfort. 

The patient is seen for bladder issues. Physical therapy is recommended. She flew home for a pass for a week. Upon return, she is frequently tearful and reports suffering from intolerable depression that she is afraid will not stop. She reports an increase in self harm urges and suicidal ideation. She says that she does not intend to act on them but states that it is really hard, and she is scared. She is very tearful. 

Approximately two weeks later, she presents as being in much better spirits. A few days after she reports ongoing severe depression, distressing enough that at some point she feels she will reattempt suicide. She reports feeling disconnected and hopeless and with a lot of dark thinking. She states that suicidal thoughts have reemerged. She states that she is worried about her thinking, that last night she was thinking about suicide. She reports that she has frequent thoughts of suicide with no specific plan. She is concerned about making it through the weekend without clinical support. She presents as depressed and is tearful. She reports hopelessness and states that life is not worth living. She reports being very depressed. She is prickly, evasive and rude in therapy. She reports having had more suicidal ideation than previously indicated. She did not take her PRN medication (as-needed) last night because she wanted to commit suicide and thought if she felt better, she would decide not to. She stated that she does not have a plan but often muses about ways she could do it. She presents as highly depressed and also gamey. She is on safety for a suicide attempt last weekend. She refuses to go to class, saying that this program is not working, and she needs to go somewhere else. She lies on the floor, saying that she is queasy and refuses to go to the rest room, instead throwing up three times while lying on the floor. Her parents express frustration that she is on too many medications. It is once more explained to them that while the program would like to reduce her medications that cannot happen when she is actively reporting suicidal ideation. She flies home for a pass. 

Upon return, the patient has continued to struggle with motivation, not caring about going up levels. She reports suicidal ideation as recently as the day before, at an intensity of 5, when she can tolerate a 5 or 6. She had self-harm thoughts last week. She is not taking care of her trench foot at night. 

The patient has turned a corner in the last month, taking on leadership roles. She feels good acting under pressure and being a good example. Her energy is lower, likely related to a peer leaving. Some significant changes have happened in terms of family dynamics, taking her out of the role of the acting out child. She has stabilized and is no longer actively suicidal. This would be a good time to undergo medication simplification. She flies home for a pass. 

The patient continues on a Neurontin taper. She feels more anxious and paranoid at times, feeling that everyone is out to get her. She returns from a home visit which she states was great. A discharge summary indicates that at admission the patient reported a history of frequent suicidal ideation with planning. She would reportedly refuse to attend school, was socially withdrawal and had few healthy peer relationships. On admission she was highly suicidal and this continued on and off through much of her stay, As late as the spring, she admitted to saving Tide Pods "just in case," so that if things were to become bad enough she would have an out. She was able to throw them away and acknowledge she no longer felt that way. She initially relied on pathology for identity and connection. She has made the most gains in this area, no longer identifying with her pathology. 

In terms of prognosis, the patient has historically engaged in cycling mood disruptions in which she becomes depressed enough not to try, which is a concern. She will be discharged home and to remote schooling. She was tapered off of Neurontin and Abilify. A decrease In Zoloft led to spikes in anxiety and a suicide attempt. 

Yes, the Continued Resident Mental Health Services was medically necessary. 

Records indicate that the patient continued to require the intensity, safety and restrictiveness of a residential treatment program after her admission. She continued to express and exhibit suicidal ideation and behavior, including stockpiling detergent to ingest, running in front of a car, and keeping a PRN (as-needed) medication so that she would continue to have suicidal ideation. Her history had included a serious overdose with intent and disappointment that she had not succeeded. Previous hospital, PHP (partial hospitalization program) and wilderness therapy admissions, as well as outpatient treatment, had not led to an increase in her ability to keep herself safe. During this admission, she additionally continued to exhibit significant difficulty with self-care, including not adequately hydrating herself leading to urinary issues, not taking adequate care of a fungal infection, and lying on the floor as she repeatedly vomited. It is not until summer that her suicidal ideation and behavior have stabilized enough so that her medications could begin to be simplified, which had been a treatment goal for the treatment team and the patient's parents; an earlier attempt to lower a medication had led to her running into traffic. By the time of discharge, while the patient continued to have issues requiring less intensive treatment, she had made significant gains in her identification as being a sick person who was destined to kill herself, leading to her being able to be safely discharged. The residential admission was medically necessary and provided treatment which led to significant improvement in her condition.