Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Depression
Treatment:  Intensive outpatient mental health treatment 
The Intensive outpatient mental health treatment was not medically necessary.

The patient is a male.  He was admitted to this adult residential treatment facility onafter a 2 12 day assessment process.  An appeal letter from the facility notes that the average length of stay is between 12 and 18 months for individuals with "serious mental illness and substance use." 

A referral from the patient's outpatient therapist reported that the patient had a history of depression, emotional dysregulation, attention deficit disorder, suicidal ideation and gestures, as well as "family and peer group attachment trauma."  The patient reportedly had been in therapy since the sixth grade after putting a knife to his throat, a gesture he repeated on two subsequent occasions since that time.  He had been on and off psychotropic medication for years but continued to struggle with depression and suicidal ideation.  The patient's therapist reported that she treated the patient for bipolar II disorder and borderline personality disorder and that his problems included suicidal ideation, mood swings, irritability, impulsivity, intense social anxiety, and high emotional reactivity, especially to perceived slights. 

The patient lived with his mother, with whom he had a strained relationship, sometimes resulting in explosive expressions of anger such as screaming, cursing, name-calling, destruction of property, and threats of suicide.

During the first part of the patient's stay, he was described as requiring close observation due to suicidal ideation.  He had difficulty processing any type of change and created issues with peers and staff. 

Progress notes indicate that the patient calmed down and had sustained improved behaviors over the first several months of treatment.  A family contact telephone note stated that the patient had not had any medication updates and that he "is coming into a leadership role and advocating for himself."  It reported that the "honeymoon phase" was over in the family session and that the patient had been "emotionally worked up" during the week.  A nursing note on that date reported that the patient initially appeared sad while at the center, but then he appeared upbeat and excited after being shown a place close to the center to play basketball.  He performed his ADLs (activities of daily living) independently.  He completed his chores unprompted.  He had no adverse reactions to medications. 

A treatment note reported that the patient was "working on reconciling his thoughts and feelings about being loved and having some anxiety about a new roommate, but was overall doing well." 

A treatment team consultation note reported that the patient was "doing really well with his nutrition and taking ownership over his meal planning."  A note stated simply that the treatment team was assessing the patient for transition to the next level of care and seeing how he did with family contact. 

A progress note reports that the patient was starting to create his one-month transition plan to semi-independent housing.  Some anxiety regarding changes was noted.  A consultation note made no mention of suicidality or acting out behaviors.  It reported that he was applying interpersonal skills toward a newer client in the house.

The customary and generally accepted standard of care for the treatment of patients with borderline personality disorders involves ongoing traditional outpatient treatment with intensification of care reserved for brief acute exacerbations.  By the date in question, there was no evidence of suicidality, disruptive behaviors, severe mood instability, reaction to medications, or other problems which could not have been treated equally safely and effectively at a less intensive level of care.