Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Major Depressive Disorder

Treatment: Intensive outpatient (IOP) mental health treatment

The insurer denied coverage for IOP mental health treatment.

The denial is upheld.

This is the case of a teenage male who was in this mental health intensive outpatient program treatment (IOP) due to depressive symptoms including depressed mood, negative thinking, low energy, decreased self-esteem, isolating, increased sleep and appetite, anxiety about returning to school, and he reportedly had a hard time when he was in school keeping up with schoolwork. Stressors included his parents getting a divorce and he lived in a duplex in the house with his mother while his father lived on the other side. He had a reported diagnosis of major depressive disorder.

The American Psychiatric Association (APA) Practice Guidelines for the treatment of Patients with Major Depressive Disorders reports that the determination of an appropriate setting for treatment should include consideration of the patient's symptom severity, co-occurring psychiatric or general medical conditions, available support system, and level of functioning. The determination of a treatment setting should also include consideration of the patient's ability to adequately care for him- or herself, to provide reliable feedback to the psychiatrist, and to cooperate with treatment of the major depressive disorder. In this case this patient had no further reports of significant depressive symptoms requiring 3 days per week treatment. 

Notes reported appropriate affect and cognitive functioning. It was reported that interventions included problem solving, support, and exploration. It was reported that he was trying to avoid unhealthy options. There were no reports of major depressive episodes, significant impairment in functioning, and there were no reports of specific identifiable or quantifiable treatment objectives that could only be achieved in a 3 days per week 3 hour per day IOP treatment setting or that could not be achieved in a less restrictive setting. Other notes reported that he had appropriate affect and cognition, and it was reported that interventions included problem solving, support, and exploration. It was reported that he was curious how to adapt to good changes and resist urges to adapt to bad habits. It was reported that he shared that he felt like he had a strong sense of self and was able to express himself without fear of judgment from others. Notes reported that his mood was pretty good, he was happy to see his friends in school again as that resumed, and he did not feel that he needed continued IOP treatment. He stated that he learned the importance of open communication and coping skills, denied depression or anxiety, suicidal or homicidal ideation, urges to self-harm, hallucinations, and was sleeping and eating well, had normal speech, clear and organized thoughts, good insight and judgment, and impulse control. 

The medical records provided did not support the continued need for 3 days per week 3 hours per day mental health IOP.

The health care plan acted reasonably and with sound medical judgment and in the best interest of the patient. This reviewer agrees with the decision to deny coverage as the medical records did not provide enough specific evidence to support the need for this level of care.

The insurer's denial of coverage for intensive outpatient (IOP) mental health treatment is upheld. Medical necessity is not substantiated.