Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Neurocognitive Disorder
Treatment Inpatient Mental Health Treatment
The insurer denied the Inpatient Mental Health Treatment
The determination is overturned.

This is a patient with a neurocognitive disorder best characterized as traumatic brain injury with behavioral disturbance arising from complications of encephalopathy. The patient has a moderately severe mood disorder associated with affective instability and aggressive outbursts with destruction of property, self-harming behavior that has included banging her head and swallowing objects, and aggression towards others and property in severe instances of impulsive aggression.
The complications of the brain injury occur together with past diagnoses of neuro-developmental disorder, mild intellectual disability/disorder, attention deficit disorder, and impulse control disorder with other disruptive and problematic behaviors requiring safety monitoring and one-to-one observation. The patient has received mental health treatment with various levels of care including extensive treatment in the past that included therapy and medication with family support and involvement. Despite the best efforts of her community, the patient remains symptomatic and requires direction with basic care and disturbances of behavior that include impulsive aggressive, self-destructive and oppositional behaviors with family and peers.
The patient is judged to be at moderate risk for self-harm and risk for impulsive and aggressive behaviors and has experienced functional impairments and deterioration with regard to relationship functioning, together with safety concerns and the continued need for intensive services with intensive therapy and safety monitoring and efforts to address life skills and social functioning. Prior to referral for neuro-rehabilitation services, the patient was participating in an Adult Day Program and living in a residential facility for individuals with autism (autism spectrum disorder and/or intellectual disability).
The patient presented with anxiety, depression, hopelessness, and affective instability with limited insight and impaired judgment associated with anxiety symptoms that were prominent; she exhibited coping and personality traits that reflected poor control of impulses with high risk for repeated violations of boundary issues and problems with maintaining emotional control in the context of the neurocognitive disorder, mood disturbance, and impulse control problems associated with the underlying traumatic brain injury (TBI).
There were no acute general medical conditions or substance use disorders in this case. The patient did not have a history of disordered eating. The patient had been prescribed mood stabilizing and antidepressant medications to address anxiety, depression, and her aggressive outbursts: Depakote, Invega, Tegretol, Topamax, Lamictal, Latuda Vyvanse and trazodone, as well as vitamin supplements and melatonin.
The patient's inpatient treatment is to include neuro-rehabilitation services and continued mental health services with intensive therapy services and safety monitoring together with the intensity of treatments and structure of an inpatient (or high-intensity residential level of care) with additional services to include speech and language assessments, nutritional assessments and behavior modification techniques targeting the impulsive aggression. She received comprehensive psychiatric evaluations with the development of a treatment plan including continuing medication management. The treatment plan included therapeutic interventions to improve coping skills and self-esteem, and the treatment plan included the goals of breaking the cycle of self-destructive behaviors including self-harm; and, the development of healthy relationships and functioning. The program focused on organizational skills; self-care; peer relationships; and other life skills, as well as behavioral and emotional regulation with milieu, individual, group, family, and activity therapies, and other interventions aimed at improving life skills.
The patient is to actively participate in the treatment plan and work on therapeutic, social, and emotional functions in the context of a therapeutic milieu with an inpatient rehabilitation level of structure and monitoring with a behavioral health program and setting that provided structure, intensive and evidence-based therapy, and safety monitoring, as well as ongoing interventions to address impulsivity. Life skills and other age-appropriate therapeutic interventions are provided, as the program will allow. Additionally, the patient is to receive ongoing rehabilitation and therapy to assist her to process the issues associated with her tendency for dysregulated mood and disruptive behaviors including problematic behavior related to the impulsive aggression and persistent mood disorder. Processing therapy occurs individually and in groups. The patient will also work with a life coach/counselor to address educational and vocational needs with hands on experience. The goal of the treatment plan is to allow this patient to become more independent and transition to a transitional living environment with continued treatment as a step down followed by more independent living in a less restrictive treatment setting than the previous/current treatment setting.
The appeal documentation and case records and health plan documents were reviewed including correspondence and case summaries provided by the referring clinicians and parent. The health plan's rationale for the denial of authorization for the admission and the coverage of the requested services was reviewed together with reference to the plan level of care guidelines/medical necessity criteria. 
The issue under review is the medical necessity of inpatient mental health treatment. 

The requested health service/treatment of Inpatient Mental Health Treatment is medically necessary for this patient.
The patient's clinical history and presenting features and persistent symptoms together with safety concerns warrant the admission and the continued structure and monitoring of an inpatient (neuro-rehabilitation) setting with the intensity, scope, and duration of inpatient level services in order to effectively address the patient's risk of self-harm, continue to learn adequate coping skills to engage in an ongoing therapeutic process, and prevent treatment failure, while the treatment team and family worked toward a clinically appropriate disposition with continued mental health services to address the severe and persistent symptoms of the multiple diagnosed disorders and the associated disturbances of mood, attention and functioning.
The inpatient level services are medically necessary in order to effectively address the patient's risk of aggressive and problematic behaviors, continue to learn adequate coping skills to achieve better control of impulses and boundaries with peers and family, and prevent treatment failure as she had previously experienced, while the treatment team and family worked toward a clinically appropriate disposition with continued mental health services to address the co-occurring mood and attentional and anxiety and neurocognitive disorders including the use of behavioral techniques to address the aggressive and disruptive behaviors in this patient.
The patient had a history of failing to benefit from prior treatment episodes and demonstrated residual symptoms and behaviors that had persisted despite multiple treatment episodes; and, the patient lacked the insight and control of impulses to remain engaged in treatment in a less restrictive setting during the time frame under review. The serious behavioral disturbances have persisted in the context of severe symptoms of mood disorder with co-morbid traumatic brain injury/neurocognitive disorder and mild intellectual disability that complicates the case and warrants the treatment with neuro-rehabilitation and behavioral interventions targeting neurocognitive disorder and comorbid psychiatric disorders including aggressive behavior and mood disturbance with affective instability. The treatment plan also serves to modify or eliminate high risk behaviors that represent imminent and ongoing risk for harm to self or others. These factors support the assertion that the patient could not have been effectively treated at a lower level of care until which time the patient is working on the psychological issues associate with brain injury with improved insight and impulse control and coping skills as outlined in the goal of treatment for improved independence and ability to live in a less restrictive treatment setting as opposed to her prior living situation.
This answer is in keeping with prevailing standards of medical practice and consistent with the scientific literature and guidelines, referenced below.