Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Mood Disorder
Treatment: Continued Residential Mental Health Treatment
The insurer denied Continued Residential Mental Health Treatment.
The determination is overturned.

The patient was referred to residential treatment by her outpatient clinician with severe symptoms of a treatment refractory mood and trauma related disorder and co-occurring substance use disorder. The patient had become increasingly anxious and depressed with suicidal ideation and deterioration in functioning despite several treatment episodes that included psychiatric hospitalizations and multiple medication trials, as well as electroconvulsive therapy and ketamine infusions without sustained benefit or response. She had received ongoing psychotherapy which had failed to produce a response or remission. She was diagnosed with bipolar I mood disorder with psychotic features including paranoid thought content, posttraumatic stress disorder (PTSD), and co-occurring substance use disorder with alcohol and tobacco class drugs. The patient presented with a clinical course that included multiple psychiatric hospitalizations, suicide attempts and severe substance use disorder with ongoing and escalating use of alcohol, especially after quitting her job. Her functioning had deteriorated in the context of severe psychosocial stressors that included marital stress and unemployment, and limited psychosocial support. Thus, she was referred for residential treatment to provide for more intensive treatment with monitoring and further evaluation.

The mental status examination on admission revealed a patient with sad affect and anxiety including apprehension, nervousness, tension, and excessive worry. Sleep, appetite, energy levels and volition were disturbed. The patient exhibited a depressed mood with passive suicidal ideation, hopelessness, guilt and worthlessness. There was no overt psychosis or cognitive impairment or perceptual disturbance though the patient was prone to paranoid thinking. Judgment was fair, and suicidal risk was judged to be moderate to low with fair insight.

There was active substance use disorder with alcohol and tobacco, as noted. The patient had no sober supports. There were no acute general medical conditions. Physical examination and laboratory assessment were normal or negative or unremarkable. She had chronic conditions including hypothyroidism with low-normal parameters and an essential treatment with associated treatments including Lamictal, lithium, quetiapine, Wellbutrin, Primidone, propranolol and Cytomel. She had been placed on vitamins and supplements, as clinically appropriate, and was prescribed lorazepam as needed for anxiety.

The patient was married, unemployed and was living with spouse with a conflicted relationship, as noted. There are no legal issues and a complicated trauma history.

The patient was admitted with plans for a comprehensive evaluation with safety monitoring structured milieu therapy, and resumption of pharmacotherapy and psychotherapy The patient initially had a difficult clinical course with severe symptoms of anxiety and mood disturbance that limited her ability to engage with treatment. Her medications were adjusted included downward titrations or discontinuation of medications to simplify her psychotropic regimen. Psychological testing was provided to affirm her diagnoses and inform treatment.

During her continued stay, the patient became increasingly cooperative and receptive with treatment and social with peers with continued mood disturbance, affective instability and sleep disturbance. She received motivational interviewing and enhancement with regard to the substance use disorder, and dynamic and behavioral therapy with focus on mindfulness and distress tolerance, as well as emotional regulation, and trauma recovery. She denied active suicidal ideation, plan or intent during this time interval, but had continued evidence for passive suicidal ideation with continued risk. Insight, judgment and impulse control remained fair.

The treatment plan going forward included continued therapy with focus on the mood disturbance and trauma recovery, family-focused sessions to address issues within the marital/family constellation, and other interventions within the therapeutic milieu with the intensity of services, structure and monitoring of a residential program including sustained abstinence from alcohol and efforts at smoking cessation.

The issue under review is the medical necessity of Continued Residential Mental Health Treatment.

The requested health service/treatment of mental health residential treatment is medically necessary for this patient.

In this case scenario, the patient required the admission and the continued residential level care in order to remain safe and to administer treatment for her psychiatric disturbances while conducting an evaluation, and while observing her functioning with the resumption/adjustment of clinically appropriate medications to address the mood disturbance and stabilize mood while implementing evidence-based treatments to address the comorbid conditions, PTSD and the co-occurring substance use disorder. The clinical course is complicated by her past history of suicide attempts and suicidal risk during the time interval under review. Additionally, the treatment team was planning for an extended stay with intensive treatment targeting mood with trauma recovery in order to develop a safe and clinically appropriate disposition and discharge plan that would allow for a safety plan and efforts to address the co-occurring substance use disorders with alcohol and tobacco.

The medical necessity for residential level structure and monitoring is reasonable and in the patient's best interest in view of the patient's severe symptoms of mood disorder and comorbid mental and substance use disorders including continued risk for suicidal behavior; in view of these clinical features and the complicated presentation with comorbidities, continued active treatment with safety monitoring was warranted in the context of the patient's deteriorated functioning and severe psychosocial stressors. Additionally, the residential stay during the time interval under review is medically necessary in order to monitor the response to medications, to assure that the patient will have a sustained response to treatment, and to continue to address the risk of suicidal behavior in the context of severe symptoms of bipolar mood disorder and severe psychosocial stressors including marital conflict. The necessity for the admission and the continued residential mental health services reflects sound medical judgment in keeping with prevailing standards of professional practice, and with the published guidelines and criteria, referenced below.. This answer is consistent with prevailing standards of professional practice, and with the published guidelines and criteria, referenced below, including the American Society of Addiction Medicine (ASAM) Criteria, New York State Office of Alcoholism and Substance Abuse Services (OASAS) Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) Criteria and Level of care utilization system for psychiatric and addiction services (LOCUS) Guidelines, as well as the scientific literature referenced below.