Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Obsessive Compulsive Disorder and emotional dysregulation.
Treatment: Partial Hospitalization Mental Health Treatment, Service Code F42.2.
The insurer denied coverage for the Partial Hospitalization Mental Health Treatment, Service Code F42.2.

The denial is overturned. 

This patient, who identifies as a transgender male, was admitted to mental health partial hospital program due to severe obsessive compulsive symptoms and emotional dysregulation. The patient reportedly had intrusive thoughts, compulsive ritualistic and checking behavior including sometimes taking 4 hours prior to work which resulted in inability to work and also to have medical leave of absences at school. The patient also reportedly had self-injurious behavior, and physical aggression and anger; and had police escorts to the Emergency Room (ER) in restraints. The patient had reports of gender and body image issues which worsened obsessive compulsive symptoms and emotional dysregulation. The patient reportedly had a diagnosis of Obsessive Compulsive Disorder (OCD), as well as Autism Spectrum Disorder and Body Dysmorphic Disorder. The patient reportedly had psychiatric hospitalizations including 3 days while in this partial hospital program. The patient had medication management and intensive treatment 5 days per week while living in a supportive living facility. The patient was referred to this specialized partial hospital program by the outpatient psychologist who reportedly was doing 2 sessions per day of treatment and recommended more intensive treatment. 
 
The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Obsessive Compulsive Disorders reports that the least restrictive level of treatment for safe and effective treatment is appropriate and that longer durations of treatment are often necessary to treat OCD as this is a difficult disorder to treat. This was the case for this patient. 

In this case, this patient required at least this level of care and for the allotted duration as the patient had severe obsessive compulsive symptoms, emotional dysregulation, self-injurious behavior including head banging, physical aggression, gender and body image issues contributing to worsened symptoms, poor functioning including inability to work or remain in school, and also required multiple psychiatric hospitalizations. It also was reported that the patient was attending outpatient sessions and required more intensive daily treatment. This patient had severe obsessive compulsive symptoms significantly interfering with functioning and also putting self and others at risk of danger. The patient had reports of suicidal statements. It was reported that while in this partial hospitalization program setting, the patient had such severe intrusive thoughts and gender dysphoria and sexual orientation issues that the patient began head banging on the counter, crying, and yelling and required a police escort and 3-day hospital stay. The patient reportedly had extreme guilt and shame which exacerbated emotional dysregulation leading to self-destructive behaviors. There was a family history of suicide which also increased the suicidal risk for this patient. The patient reportedly was discharged to another facility for further intensive mental health treatment. This was a high risk patient with severe obsessive compulsive symptoms, gender issues, emotional dysregulation, and self-destructive behaviors with inability to function. The patient also required a 3-day hospital stay during partial hospitalization program treatment. Thus, the patient required at least this partial hospital program level of care treatment.

The health plan did not act reasonably with sound medical judgment, and in the best interest of the patient. 

The medical necessity for the Partial Hospitalization Mental Health Treatment, Service Code F42.2 is substantiated.  The insurer's denial should be overturned.