Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Posttraumatic Stress Disorder (PTSD)
Treatment: Mental Health Services
The insurer denied the Mental Health Services.
The health plan's determination is overturned. 

The patient is an adult female admitted for residential mental health treatment in order to address severe complex posttraumatic stress disorder (PTSD) with comorbid major depressive disorder and skin picking disorder, as well as borderline personality traits with history of self-harming behavior (cutting and punching the wall) and suicidal behavior with at least two suicide attempts and other threats of suicide. The patient has co-occurring substance use with use of cannabis, and history of substance-induced mania and aggressive behavior directed towards her sister. She had posted videos outlining suicide plans by carbon monoxide poisoning and threats to jump from a building, as well as threats to overdose with at least two inpatient psychiatric hospitalizations. The patient was admitted for low-intensity residential treatment following a three-month high intensity residential stay which had followed the last inpatient psychiatric hospitalization. The residential program focused on trauma recovery and addressing suicidal and self-harming behaviors, as well as services to address the substance use disorder and impulsivity.
Despite treatment with therapy and antidepressant medications, the patient's mood and comorbid disorders had worsened with persistent suicidal ideation in the context of apathy and dysregulated emotions including suicidal ideation and aggressive impulses towards self with cutting/self-harming behavior and others when under the influence, including psychotic features and impulsive aggression. There was no evidence for mania other than substance induced mania, thought disorder or perceptual disturbance except a report of visual hallucinations while prescribed Prozac. The patient does dysregulate when experiencing trauma-related symptoms and reports nightmares. Insight and judgment were limited and marginal due to the multiple psychiatric conditions and substance use together with safety concerns.
At issue is the medical necessity of Mental Health Services.

The requested health service/treatment of Mental Health Services was medically necessary for this patient.
The admission and continued residential services were clinically appropriate and the services provided were not amenable to treatment at a lower level of care. The patient was working to learn improved coping skills and life skills together with the development of improved insight and motivation, as well as psychosocial and psychotherapeutic treatment to address the complex PTSD and mood disorder and substance use disorder and other evidence-based interventions to address the continued urges to self-harm in the context of borderline personality traits, critical in this case scenario. The admission was appropriate, and the patient did warrant the continued structure and monitoring of a residential setting in order to safely continue mental health treatment and services while maintaining safety with high risk for suicide or acting on aggressive impulses towards self or others. There were severe psychiatric symptoms including complications related to trauma history. Thus, the requested services are clinically appropriate and consistent with prevailing standards of professional practice and consistent with published guidelines (best practice).
The patient's Mental Health Services were in the patient's best interest, reasonable, clinically appropriate, and therefore, medically necessary.