Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Major Depressive Disorder
Treatment: Continued residential mental health treatment
The insurer denied coverage for continued residential mental health treatment
The denial is overturned

This male reportedly was admitted to this inpatient mental health residential treatment due to depressive symptoms, anxiety, and cannabis use. He reportedly had depressed mood, suicidal ideation, poor motivation and concentration, lack of interest and pleasure, feelings of hopelessness, feeling overwhelmed, school refusal, and behavioral issues including poor impulse control, attention problems, distractibility, and difficulty with completion of tasks. He reportedly had past school suspension for vaping in school, was self-medicating with cannabis, had past property destruction when angry including kicking doors and breaking a phone, as well as aggression by pushing his father. He had reported diagnoses of Major Depressive Disorder, Generalized Anxiety Disorder, Social Phobia, and Cannabis Use Disorder. He reportedly had Zoloft increased, attended individual, group, and family therapy.

The 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 he required this level of care then still. 

The MCG (Milliman Care Guidelines) Residential- Behavioral Health Level of Care- Psychiatry 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, this patient continued to have at least moderate psychiatric symptoms and did not have the coping skills to deal with his multiple psychiatric issues, eating disorder issues, and substance use. For discharge it states that there needs to be sufficient support at a lower level of care, absence of suicidal or homicidal thoughts or thoughts of harm to self or others. In this case, this patient did not have appropriate supervision or care as it was reported that his parent had COVID (coronavirus) and also had a flood in the house and were in a hotel, so they were unable to care for this child. This child was a minor and was not able to be discharged without appropriate supervision and care. He had poor impulse control, recent depressive symptoms, past aggression and property destruction, past suicidal ideation and hopelessness as well as major depressive symptoms, and he required 24-hour supervision, structure, and safety in this 24-hour therapeutic residential treatment until appropriate supervision and care was available. It was reported that his parent was sick with COVID and also displaced from their home and into a hotel due to a flood in their home, so they were not available to supervise and care for this patient. As a result, the recommendation is to overturn the previous decision and approve coverage for continued inpatient mental health residential treatment for 2 more weeks to give them time to recover from COVID and also have their home repaired. The reviewer recommends another review by the insurer then if the patient is still in this residential treatment setting to assess further treatment needs then. It did not appear that the insurer acted reasonably or in the best interests of the patient then.

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