Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Schizo-Affective Disorder; Bulemia Nervosa. 
Treatment: Mental health services in a residential treatment setting. 

The insurer denied coverage for mental health services in a residential treatment setting. 

The denial is overturned. 

This female patient was admitted for inpatient mental health treatment in a residential treatment facility due to mood and psychotic symptoms including suicidal and homicidal ideation, auditory hallucinations, paranoid and disorganized thinking, intrusive thoughts, mood instability, anxiety, depression, eating disorder symptoms, attention problems, impulsivity, poor coping skills, poor frustration tolerance, feeling overwhelmed, and interpersonal issues.  The patient has been diagnosed with Schizoaffective Disorder-Bipolar Type, Attention Deficit Hyperactivity Disorder (ADHD), and Bulimia Nervosa.  The patient had multiple past psychiatric hospitalizations due to suicidality, assaulting her father, and jumping out of a moving car. The patient had medication changes and was taking Lithium and Zoloft. The patient was then discharged. 

The MCG Residential-Behavioral Health Level of Care- Psychiatry guidelines report that one needs to have continued danger to self or others still in the form of auditory hallucinations contributing to suicide or serious harm to self or paranoid delusions or auditory hallucinations contributing to risk of homicide or serious harm to others or persistent thoughts of suicide or serious harm to self or homicide or serious harm to others that cannot adequately be monitored at a lower level of care, or 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, absence of suicidal or homicidal thoughts or thoughts of harm to self or others. 

In this case, this patient continued to have severe psychiatric symptoms including suicidal and homicidal thoughts, psychotic, and severe mood symptoms requiring 24-hour residential treatment in this setting. Notes documented that the patient had continued paranoia and homicidal thoughts, depressed mood, slow speech, poor attention, and poor frustration tolerance, paranoid and disorganized thinking, isolation, and suicidal ideation with thoughts about jumping off a bridge. The patient had intrusive thoughts to hit someone.  During her stay, notes continued to show that the patient had depressed mood, suicidal thoughts, and intrusive thoughts to harm someone, paranoid thinking, mood instability, and limited insight. The patient had suicidal and self-harm thoughts, paranoia, depressed mood, low energy, and she had to isolate due to COVID positive testing.  When the patient denied suicidal or homicidal ideation or psychotic symptoms; the patient was then considered stable and was discharged. 

Based on the review of the medical record, the patient continued to have suicidal and homicidal thoughts, depression, paranoia and disorganized thinking, poor coping skills, intrusive and negative thoughts, and presented still as a danger to self and others, during the denial period. The patient had past reported suicidal behavior and aggression and had multiple past psychiatric hospitalizations and was thus, considered a high risk patient.  The patient was not considered safe for discharge outside of this 24-hour therapeutic, supervised and structured residential treatment setting until discharge. Thus, continued mental health services in a residential treatment setting is considered medically necessary for this patient. 

The health plan did not act reasonably with sound medical judgment and in the best interest of the patient. 

Based on the above, the medical necessity for mental health services in a residential treatment setting is substantiated. The insurer's denial should be overturned.