Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Unspecified mood disorder, Oppositional defiant disorder

Treatment: Continued inpatient mental health treatment

The insurer denied coverage for the continued inpatient mental health treatment.

The denial is overturned.

This is a female child who was reportedly admitted to inpatient mental health treatment in the hospital due to depressive and behavioral symptoms including suicidal ideation and plan to overdose, depressed and irritable mood, mood swings, physical aggression towards her mother and peers, destruction of property, self-injurious behavior including cutting self and a recent suicide attempt by overdose of Benadryl 2 weeks prior to admission. She reportedly had dangerous behavior including running away, poor impulse control and decision making, poor frustration tolerance, and isolative behavior as she reported having no friends. She had past inpatient mental health treatment including a past hospitalization and 3 month wilderness stay. She had reported diagnoses of unspecified mood disorder and oppositional defiant disorder. It was reported that her mother did not feel safe taking her home and recommendation was for mental health residential treatment upon discharge from the hospital. She had interviews with residential treatments and was discharged to a residential treatment after months of treatment in the hospital.

The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Suicidal Behaviors reports that patient with past suicide attempts are at high risk of suicide and this patient had a past reported suicide attempt 2 weeks prior to admission to the hospital.  She continued with mood instability, depressed and irritable mood, poor angry and impulse control including punching walls and hurting herself as well as aggression towards others. Her mother reported that she did not feel safe taking the patient home due to her aggressive behaviors towards her mother and peers, dangerous behavior including running away, property destruction, and she was considered a danger to self and others still and in need of 24 hour hospital treatment until her discharge to the residential treatment. She also had some reported improvement with her current treatment in the hospital including pharmacotherapy and medication increases as she had less reported overall depressive symptoms and aggression even though she still had reports of these symptoms and also had less reports of suicidal thinking which was progress and not custodial care. She required one to one observations and had an active psychiatric treatment plan, not custodial.  

The chart notes support that she required this inpatient mental health treatment in this hospital including from week 10 of admission onward as she had continued mood and behavioral symptoms but had reported progress with psychiatric treatment plan and that she required 24 hour hospital treatment until discharge to the 24 hour therapeutic residential treatment. Continued inpatient mental health treatment in this hospital from week 10 of admission onward was medically necessary. It did not appear that the health care plan acted reasonably or with sound medical judgment or in the best interests of the individual then.

The carrier's denial of coverage for the continued inpatient mental health treatment is overturned. The medical necessity is substantiated.