Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Emotional dysregulation, mood swings, depressed and irritable mood

Treatment continued residential mental health services

The insurer denied coverage for continued residential mental health services

The denial is overturned

This patient was admitted to inpatient residential treatment due to emotional dysregulation, mood swings, depressed and irritable mood, suicidal ideation, past suicide attempts including overdose, self-harming behaviors, anxiety symptoms, oppositional defiant behavior, attention problems, poor impulse control, illicit substance use, drug cravings, selling his medications to but illicit substances, parent child relational issues, past aggression and agitation, lack of flexibility, poor coping skills, lack of insight, poor decision making, and reports that he was sneaking out of the house and selling his medications. He had 2 past reported suicide attempts. He was in a wilderness inpatient program who recommended inpatient residential treatment. He had past intensive outpatient and day treatment as well as multiple past outpatient treatment and still struggled with mood and behavioral issues. He had multiple medications changes, attended group, individual, and family therapy. He was discharged. 

The Milliman Care Guidelines (MCG) Residential-Behavioral Health Level of Care- Psychiatry guidelines report that one needs to have continued danger to self or others, moderately or severe psychiatric or behavioral symptoms requiring 24-hour daily treatment, or serious dysfunction in daily living. For discharge it states that there needs to be sufficient support at a lower level of care, absence of suicidal or homicidal thoughts or thoughts of harm to self or others. In this case this patient continued to have moderate psychiatric symptoms and drug cravings and was considered at risk to self if discharged from a 24-hour therapeutic supervised and structured residential treatment setting as he still did not have adequate enough coping skills to function safely outside of this residential treatment setting. He reportedly had a recent 24-hour wilderness program for 11 weeks and they recommended more intensive 24-hour residential treatment. He also reportedly had past day treatment and intensive outpatient program (IOP) and outpatient treatments and still struggled with emotional dysregulation, mood, and behavioral symptoms, including self-harm and aggressive behavior, agitation, poor impulse control, and past suicidal attempts. 

He was making some progress but still needed more time in this facility to continue to learn better coping skills, decision making, impulse control, and improve insight, better regulate emotions and behavior. He was considered at risk for suicide due to his emotional dysregulation, past suicide attempts, illicit substance use with continued cravings, and mood symptoms. He was discharged. He was not considered safe for discharge outside of this 24-hour therapeutic, supervised and structured residential treatment setting until discharge. As a result, the recommendation is to overturne the previous decision and approve coverage for continued inpatient residential treatment. 

The health care plan did not act in the best interests of the patient.

The insurer's denial of coverage for continued residential mental health services is reversed. Medical is substantiated.