Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Bipolar disorder, ADHD. 
Treatment: Intensive Outpatient Mental Health Services. 

The insurer denied the Intensive Outpatient Mental Health Services. 
The denial is upheld. 

The patient is a male who was admitted for residential treatment of a mood disorder diagnosed as bipolar I disorder and comorbid attention deficit hyperactivity disorder (ADHD), predominantly hyperactive type; and, other behavioral problems associated with impulsive, conduct and disruptive behaviors (stealing, lying, self-harming and suicidality), as well as problems with school related to his unspecified disruptive, conduct and impulse behaviors that were also experienced at home. The patient had received prior outpatient, partial hospital program (PHP) and inpatient level services; he had received Wilderness Therapy immediately prior to the referral for residential level services, as well as past involvement in psychotherapy including family focused sessions. The admission to residential services followed a progression of disruptive and problematic and high-risk behaviors that had included mental health issues; impulsive aggression towards self; and impulsive behaviors driven by affective instability and emotional dysregulation / dysregulated mood despite treatment in the community. He also had a history of school refusal. There was substance use with cannabis as a drug of choice, and with tobacco / nicotine use. 

The patient presented with the mood, attention and impulse disturbances with limited insight and impaired judgment; he exhibited coping and personality traits that reflected boundary issues and poor control of impulses in the context of the attention deficit hyperactivity disorder (ADHD) and bipolar disorder. He related conflict with peers and family problems with interpersonal relation problems with peers and a decline in functioning over the course of four to five years when his mental disorder was initially diagnosed. 

No, the proposed treatment, continued residential mental health treatment billed and depicted as intensive outpatient program (IOP) level of care was not medically necessary for this patient. 

The residential mental health services billed as intensive outpatient program (IOP) level of care going forward would have been reasonably amenable to treatment at a lower level of care and therefore excluded from coverage under the plan, as not medically necessary. During this time interval, the patient had effectively engaged in mental health treatment and services; he was able to learn and demonstrate improved coping skills and impulse control, gain insight with respect to his behavior, and develop life skills, as well as ongoing family focused sessions and support. He demonstrated improved sleep, concentration and volition with mood stabilization and improved control over symptoms related to the attention deficit hyperactivity disorder (ADHD) and impulse / disruptive behavior. He did not need the continued structure or monitoring of a residential setting billed as intensive outpatient program (IOP) level care in order to safely continue the mental health treatment and services with lower level care in the community. There were no remaining biomedical or psychiatric complications, or severe psychiatric symptoms that would have required continued residential level or intesnive outpatient program (IOP) level services beyond the initial approved timeframe. Thus, the requested services are not consistent with prevailing standards of professional practice (best practice), and the scientific literature, and practice guidelines referenced below. Additionally, medical necessity is not met for the continued residential mental health treatment billed and depicted as intensive outpatient program (IOP) level of care in keeping with New York instruction for this review. 

Moreover, the appeal is not valid in this case scenario (see below) and the health plan's reason for denial is reasonable and appropriate in this case scenario indicating as follows: the patient is in residential treatment and not intensive outpatient program (IOP); the patient is engaged in treatment and has family support; the patient has had multiple home passes without incidence; self-harming behavior is under control and safety concerns are at lower risk and can be managed with lower level of care, as can medication management and adjustments of medications. 

In Summary, the health plan should not cover services as medical necessity is not met and the continued residential mental health treatment billed and depicted as intensive outpatient program (IOP) level of care is not warranted as the health plan asserts with the stated reasons for denial and in keeping with the practice guidelines referenced below including the American Academy of Child and Adolescent Psychiatry (AACAP) Child and Adolescent Service Intensity Instrument (CASII) service intensity instructions pertaining to risk of harm, functional status, co-occurring disorders, the recovery environment, psychosocial stressors, response to treatment and level of participation and engagement with the treatment.