Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Unspecified Disruptive Impulse-Control, Conduct Disorder, Cannabis-Related Disorder, Reactive Attachment Disorder
 
Treatment: Mental health residence

The insurer denied coverage for mental health residence. The denial is upheld. 

This patient is a male who was admitted to this inpatient mental health residential treatment due to behavioral symptoms including disrespectful behavior, verbal abuse at times, property damage, truancy at school, and taking items from the home. He also demonstrated impulsivity, hyperactivity, and it was reported that he had a change in attitude towards his family, school, and sports since several years ago. He had reported diagnoses of Conduct Disorder, Attention Deficit Hyperactivity Disorder (ADHD), and Cannabis Use Disorder. 
	
The insurer denied coverage for inpatient mental health residential treatment as not medically necessary treatment. This reviewer agrees with the decision to deny coverage for inpatient mental health residential treatment as the chart notes do not provide enough specific evidence to support that he could only be treated in a 24-hour residential treatment or could not be treated in a less restrictive level of care.

The American Academy of Child & Adolescent Psychiatry (AACAP) Practice Parameters for the Assessment and Treatment of Children and Adolescents with Conduct Disorder report that the least restrictive level of care for safe and effective treatment is appropriate.  In this case, the chart notes did not have enough specific evidence to support that he could not be treated in a less restrictive setting. Notes on admission did not report imminently dangerous behavior, suicidal or homicidal ideation, psychotic symptoms, inability to function, severe depressive symptoms, manic episodes, or dangerous substance use behavior.

Notes in early-2018 reported that his mood was anxious and within normal limits, and he was working on relationship building. They also reported that he was struggling with communication. Notes one month later reported that he was working on developing insight into how cognition precedes feelings that precede aggressive behavior.  Another month later notes reported that he was using attachment based therapy. He did not have specific reported identifiable and quantifiable treatment goals that could only be achieved in a 24-hour residential treatment setting or that could not be achieved in a less restrictive program setting.  His treatment goals of improving communication, relational issues, insight, behavioral control, and decision making did not require only 24-hour residential treatment.  Also, there was no reported specific documentation stating that he failed a less restrictive level of care, such as a partial hospital program.  Furthermore, there were no reports that he was evaluated by a child/adolescent psychiatrist during his time for diagnosis or treatment recommendations. 

As a result, uphold the previous decision and deny continued residential treatment. The health care plan acted reasonably and with sound medical judgment and in the best interests of the patient.

The carrier's denial of coverage for mental health residence is upheld.  The medical necessity is not substantiated.