Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer

The patient is a 17-year-old male who presented on 6/25/18. The records noted feelings of depression and anxiety. The patient presented as quiet and withdrawn and denied any history of substance use. Prior to his admission, the patient reported he had been in treatment with an outpatient therapist starting in April 2018 for two months. He denied any history of suicide attempts. On 7/25/18, the patient reported that his anxiety had improved since initiation of sertraline. He reported improvement in appetite and mood. The patient indicated he had a family session with his mother, stepfather and sister. His mental status examination showed that he did not currently pose a risk of harm to himself or others. His eye contact was good, and his speech was normal. His thought process was linear and goal-directed. His thought content was without suicidal ideation and without homicidal audition. His cognition was intact, and his judgment was good. He was not experiencing psychosis or mania. On 7/31/18, the patient endorsed significant improvement in his anxiety. He endorsed enhanced mindfulness and ability to enjoy himself socially. His mental status examination showed good eye contact, normal speech, euthymic affect and linear thoughts. He denied any suicidal or homicidal ideation. The patient was discharged on 8/08/18. His diagnoses included major depressive disorder, recurrent episode, severe and social anxiety disorder. The patients parent has requested reimbursement for mental health residential treatment provided from 7/18/18 through 8/08/18. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of this patient. This denial is the subject of this appeal and determination. The submitted documentation fails to demonstrate the medical necessity of the services at issue. The patient was admitted approximately three weeks prior to the date of Health Insurers denial. During his stay, the patient was noted to be cooperative in treatment. He was engaged in family and individual therapy and was noted to have significant improvement in his anxiety. As his stay progressed, the patient gained more insight into his anxiety, and he made significant progress. The records indicated that his symptoms stabilized, and he no longer needed residential treatment. The progress notes do not indicate that the patient made any suicide attempts or self-harm attempts during his stay. There was no notation that the patient had extreme mood swings or psychosis or other severe psychiatric symptoms. The patient was receiving dialectical behavioral therapy at the residential treatment center, and he could have received dialectical behavioral therapy on an outpatient basis. This type of therapy has been proven to be beneficial in reducing mood symptoms, emotional dysregulation and suicidal behavior in adolescents. Dialectical behavioral therapy is routinely provided on an outpatient basis.  The American Academy of Child and Adolescent Psychiatry and American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System can assist in determining the necessary level of care for children. In terms of risk of harm, the records support a score of 1 due to the patients lack of history of suicide attempts.  While in treatment, he was not actively suicidal. With regards to functional status, the records support a score of 3. The patient had school disruption due to anxiety. In terms of comorbidity, the records support a score of 1. The patient did not have active serious medical problems or substance use history. With regards to level of stress of the recovery environment, the records support a score of 2. The patient had a positive recovery environment and a stable housing situation. In terms of level of support of the recovery environment, the records support a score of 2. The patients family was actively involved in treatment on a regular basis. With regards to resiliency and treatment history, the records support a score of 3 due to good positive response from residential treatment. In terms of acceptance and engagement of the patient, the records support a score of 2. The patient participated in therapy and used coping skills learned in therapy. With regards to acceptance and engagement of the parent, the records support a score of 2. The parents worked actively and constructively with clinicians. Thus, the patient has a composite score of 16. This score correlates with outpatient services. Therefore, mental health residential treatment provided from 7/18/18 through 8/08/18 was not medically necessary for the treatment of this patient. Therefore, the services at issue were not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.