Appeal type: Medical necessity
Decision: Overturned

Diagnosis: major depressive disorder, autism spectrum disorder, social pragmatic communication disorder, attention deficit hyperactivity disorder

Treatment: Continued inpatient mental health residential treatment

The insurer denied coverage for continued inpatient mental health residential treatment

The denial is overturned

The patient has a history of major depressive disorder (MDD), autism spectrum disorder (ASD), social pragmatic communication disorder, attention deficit hyperactivity disorder (ADHD), anxiety, and social media addiction. She presented to the RTC [Residential Treatment Center] for treatment due to suicidal ideation, aggression, self-injurious behavior including cutting, poor emotional regulation, poor decision making and insight, extreme impulsivity, dangerous behavior including sexting adults,  extremely poor boundaries, poor social cues and communication including social pragmatics, poor attention, hyperactivity, racing thoughts, inability to assess risks of danger to self, disorganization, inability to function appropriately independently, and difficulty processing and understanding language. She was in intensive outpatient (IOP) and outpatient mental health treatment including dialectical behavior therapy and still had significant struggles and behaviors, putting herself and others at risk of danger. The patient received individual, group, family therapy, and pharmacotherapy and was taking Sertraline, Vyvanse, Clonidine, and Prazosin. 

The Milliman Care Guidelines (MCG) Inpatient Acute Residential Behavioral Health Level of Care-Child and Adolescent medical necessity 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. For discharge it states that there needs to be sufficient support at a lower level of care, and absence of suicidal or homicidal thoughts or thoughts of harm to self or others.

In this case, the medical records provided did support that the patient did not have sufficient support at a lower level of care as her family could not manage her due to her extremely impulsive and risky behaviors. She reportedly put herself at risk of danger due to sexting and poor insight as well as self-injurious and aggressive behavior. The patient lacked the social and coping skills to care for her needs and was unable to identify dangerous situations and behaviors. She had poor emotional regulation and disorganization and poor attention and executive functioning. This was a complex patient with complex needs and would have been considered a risk to self and others if not in this residential treatment setting. 

This reviewer disagrees with the decision to deny coverage for continued inpatient mental health residential treatment as the medical records provided enough specific evidence to support that without this level of 24-hour supervision and structure, the patient was at risk of putting herself in more danger. She had functional impairment, risk of danger to self, and mood and behavioral symptoms supporting intensive therapeutic 24-hour residential treatment during the denied dates of service.  She needed to learn better social and adaptive and coping skills to help keep herself safe and function more independently. She also required this therapeutic intensive, structured, and supervised level of care to address social, emotional, behavioral, and educational needs. The patient needed to remain in this 24-hour setting for safety while trying to learn better coping and social skills and emotional regulation, decision making, and impulse control.

It did not appear that the health care plan acted reasonably, with sound clinical judgment, or in the best interests of the patient.

The insurer's denial of coverage for continued inpatient mental health treatment is overturned. Medical necessity is substantiated.