Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Anxiety and Depression

Treatment: mental health services

The insurer denied coverage for mental health services

The denial is overturned

This patient was admitted to the outdoor behavioral health program. The patient reportedly had depressive and anxiety symptoms, difficulty regulating emotions, limited insight, insecurities and low self-esteem, difficulty in building social connections, conflict with parents, school failure, lying, withdrawal, alienation of peers, attention problems, revealing sensitivity to peers. He reportedly had diagnoses of Persistent Depressive Disorder, Generalized Anxiety Disorder, attention deficit hyperactivity disorder (ADHD), and Unspecified Neurodevelopmental Disorder. He attended group therapy, individual therapy, and therapeutic milieu. He made progress and was discharged and referred to for continued care.
  
The American Academy of Child and Adolescent Psychiatry's Practice Parameter for the Assessment and Treatment of Children and Adolescents with Depressive Disorders provides that the decision for level of care will depend primarily on level of function and safety to self and others.  In this case this patient had continued inability to control emotions, understand emotional regulation skills, had difficulty with expression of feelings, used withdrawal as a defense, had difficulty in building social connections, conflict with parents, school failure, lying, withdrawal, alienation of peers, and attention problems which interfered with his functioning. 

This patient reportedly made progress and improved in his ability to self-regulate emotions, reveal sensitivity to peers, self-regulate anxiety, improve insight including into parental conflict, was better able to accept limits, manage emotions, develop interpersonal relations and he benefitted from a small, structured setting with clear rules and boundaries. Outdoor Behavioral Healthcare Treatment programs offer proven and effective treatment interventions to patients that failed to improve through less intensive modalities. Scientific in peer reviewed literature support an improvement in health care outcomes for outdoor behavioral health programs and appears to have approval from regulatory bodies for his diagnoses. Outdoor behavioral health program treatment appeared to be medically necessary treatment and appeared to be the best available treatment for this patient then, and he was considered a good candidate for it then. The adverse effects of this treatment were not considered increased over other standard treatments and this Outdoor Behavioral Healthcare Treatment appeared likely to be more beneficial than other standard treatments. He reportedly benefitted from this and made progress and required the entire time and he reportedly was recommended for further treatment at another facility when discharged for continued treatment so as to sustain progress and treatment gains from this facility and also to further progress and not regress if not in a supervised and structured treatment setting. As a result, the recommendation is to overturn the previous decision and approve coverage for outdoor behavioral health program.

The carrier's denial of mental health services provided at an outpatient treatment level of care should be overturned.  It is more beneficial than any other standard treatments.