Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient is requesting reimbursement for residential treatment center (RTC) services that were provided from 5/01/17 through 5/28/17, and 7/03/17 through 7/31/17. The diagnoses were moderate alcohol use disorder, mild cocaine use disorder, major depressive disorder, and borderline personality disorder. The patient had a history of multiple overdoses and self-harming behavior. The patient had emotional dysregulation, depression, anxiety, and chronic passive self-harm ideation. On 5/01/17, the patient was admitted to the RTC. The admission evaluation showed that her thought process was organized with content centered around cutting. She endorsed passive self-harm ideation without plan or intent, and without means to accomplish. Her mood was depressed with blunted and congruent affect.  There were no perceptual disturbances; cognition was intact, and insight and judgment were fair.  She had ongoing feelings of depression, with passive thoughts of self-harm and cutting. On 5/28/17, she discharged against medical advice. After discharge, the patient overdosed and was hospitalized. On 7/03/17, she presented for residential admission. She endorsed depression and anxiety. Her treatment included medications.  Medication dose adjustments, additions, and discontinuations were made. The patient has requested reimbursement for RTC services that were provided from 5/01/17 through 5/28/17, and 7/03/17 through 7/31/17. The Health Plan denied this request and reported the services provided were not psychiatric emergency services. At issue is whether the RTC services provided from provided from 5/01/17 through 5/28/17 and 7/03/17 through 7/31/17 were psychiatric emergency services. Per Health and Safety Code section 1317.1, psychiatric emergency medical services are services needed to treat or diagnose a psychiatric emergency medical condition. Per that same provision, a psychiatric emergency medical condition is a mental disorder that is manifested by acute symptoms of sufficient severity that patients are either an immediate danger to themselves or others, or immediately unable to care for themselves due to the mental disorder. On RTC admission on 5/01/17, the patient did not demonstrate agitation, impulsivity, or evidence of self-harm intent. She was medically stable and had feelings of depression with ongoing passive thoughts of self-harm and cutting. On 5/28/17, she left the RTC against medical advice. On RTC admission from 7/01/17 through 7/31/17, the patient did not express self-harm urges or behaviors. The patient was medically and psychiatrically stable. She was not an immediate danger to herself or to others. She was not placed on an involuntary hold, and she was not immediately unable to provide for or utilize, food, shelter, or clothing due to the mental disorder. Her medication regimen did not require the hospital setting and she had a stable support system. In this case, the patient did not have a psychiatric emergency medical condition. The RTC services provided from 5/01/17 through 5/28/17, and 7/03/17 through 7/31/17 were not psychiatric emergency services.Final Result: The reviewer determined the patient did not receive psychiatric emergency medical services on the dates of service at issue. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.