Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Major Depressive Disorder

Treatment: Continued Mental Health Residential Treatment

The insurer denied coverage for continued mental health residential treatment

The denial is overturned

This patient is a female with a history of depression, anxiety, and bipolar disorder who was admitted to inpatient mental health residential treatment due to mood symptoms. The patient reportedly had depressed and irritable mood, self-injurious behavior including cutting self, poor impulse control, poor coping skills, anxiety symptoms, and mood dysregulation. The patient had multiple psychiatric hospitalizations in the past. The patient reportedly took Zoloft and Abilify. The patient was still in this inpatient mental health residential treatment as per last medical records for review.
  
Based on the review of the medical record and literature, continued inpatient mental health residential treatment was medically necessary for this patient as the medical records provided for review did provide enough specific evidence to support that this patient was still considered a danger to self and in need of 24-hour inpatient mental health residential treatment. This patient was a high risk patient who tried to kill herself by trying to jump out a window while in this 24-hour residential treatment setting; so, the patient was not considered safe for discharge outside of a 24-hour inpatient mental health setting yet. The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Suicidal Behaviors reports that patients with suicide attempts, intent, or plan are in need of inpatient treatment. This was the case with this patient. 

Notes up until the time the patient was considered safe for discharge reported that the patient still endorsed self-harm thoughts and had self-injurious behavior by cutting, was angry, and wanted to run away. The patient was worried about getting COVID. Notes indicated that when the patient had self-harm thoughts, the patient thought about going home and trying to cope in different ways. The patient had poor frustration tolerance and high rejection sensitivity. The patient had worsened suicidal thoughts and anxiety, and worsened feeling of hopelessness and tried to jump out the window but was stopped by the staff. It was reported that the patient then tried to jump out again but was stopped. The patient had worsened reported symptoms of depression. This was specific evidence that the patient was still considered a danger to self and was in need of 24-hour inpatient treatment. The patient required Thorazine as needed (PRN).  

As per medical records submitted for this review, the patient had worsened suicidal thoughts, depression, anxiety, and hopelessness and made a suicide attempt while in this inpatient mental health treatment setting. This indicated that this patient was considered a danger to self and in need of at least 24-hour inpatient mental health residential treatment.  There were no further notes for review. As a result, continued mental health residential treatment services provided was 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 the Continued Mental Health Residential Treatment Services Provided is substantiated.  The insurer's denial should be overturned.