Appeal type: Medical necessity
Decision: Overturned

Diagnosis: post-traumatic stress disorder (PTSD)

Treatment: mental health residential treatment facility

The insurer denied coverage for mental health residential treatment facility

The denial is overturned
 

This is a teenage patient with a history of post-traumatic stress disorder (PTSD), Major Depressive Disorder-Severe-recurrent, Generalized Anxiety Disorder, and Opioid Use Disorder. The patient was admitted to this inpatient mental health residential treatment due to mood, behavioral, anxiety, post traumatic stress disorder (PTSD) symptoms and substance use. The patient was reported to have mood dysregulation, aggressive and disruptive behavior, gang involvement, defiance, property destruction, poor impulse control, PTSD symptoms including intrusive thoughts, hypervigilance, and avoidance symptoms, irritable and sad mood, poor coping skills, and poor insight and judgment. The patient had a history of Percocet and benzodiazepine use, had cravings to use and reportedly glorified drug use. There was a history of multiple past treatment episodes including 2 past hospitalizations; one with a duration of 4-5 months. The patient attended individual and group therapy and was discharged.

The Milliman Care Guideline (MCG) Residential-Behavioral Health Level of Care - Child Adolescent 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. 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, the patient continued to have moderate psychiatric symptoms and did not have the reported necessary coping skills to deal with their multiple psychiatric issues and substance use as of insurer's proposed discharge date. This was a complex patient with multiple psychiatric diagnoses including PTSD, Major Depressive Disorder-Severe-recurrent, Generalized Anxiety Disorder, and Opioid Use Disorder who reportedly had property destruction while in this setting and still had cravings and lacked coping skills and enough insight to stop substance use and did not have the reported impulse control to better control behaviors and emotions and to better deal with trauma. It was reported that the patient needed more improvement in their coping skills to better deal with their psychiatric symptoms and urges to use substances. It was reported that the patient lived in a neighborhood in which there was gang involvement and readily available drugs. The patient reportedly had been involved in illegal activities when not in this treatment setting including selling drugs in addition to using them, as well as physically aggressive, threatening, and disruptive behavior, and property destruction. 

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for continued mental health residential treatment facility is substantiated.