Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Borderline Personality Disorder

Treatment: Residential mental health treatment

The insurer denied coverage for residential mental health treatment.

The denial is upheld.

This patient reportedly was admitted to this inpatient residential treatment due to mood and behavioral symptoms and anxiety symptoms. The patient reportedly had passive suicidal ideation and thoughts of self-harm, depressed and irritable mood, emotional instability, crying spells, flashbacks, dissociative symptoms, concentration problems, decreased activities of daily living (ADL's), isolation, and feelings of shame and guilt. The patient reportedly had 7 past psychiatric hospitalizations. The patient reportedly was attending group therapy and taking Sertraline for mood and anxiety symptoms. The patient had reported diagnoses of Borderline Personality Disorder, Generalized Anxiety Disorder, and Major Depressive Disorder. The plan was to step down to a partial hospital program with boarding.

The insurer denied coverage for continued inpatient behavioral health residential treatment not medically necessary treatment then. They stated that the patient did not require further 24 hour inpatient treatment, and they recommended a less restrictive level of care such as partial hospital program (PHP) treatment then. 

The Milliman Care Guidelines Residential-Behavioral Health Level of Care guidelines for adults 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. Also, the Interqual Behavioral Health Adult Inpatient Level of Care residential treatment guidelines reports that one still has to have psychiatric or behavioral symptoms that put the patient at high risk for hospitalization if not in this 24 hour treatment or that they still have psychiatric or behavioral symptoms that are improving or expected to improve but they are not clinically stable yet to step down to a less restrictive level of care. In this case it was reported that this patient had mood and behavioral symptoms and anxiety symptoms on admission and also reportedly had passive suicidal ideation and thoughts of self-harm, depressed and irritable mood, emotional instability, crying spells, flashbacks, dissociative symptoms, concentration problems, decreased ADL's, isolation, feelings of shame and guilt. However, there were no medical records for review reporting moderate to severe behavioral or psychiatric symptoms that required only 24 hour inpatient mental health treatment then or reports of specific evidence that the patient could not be treated in a less restrictive level of care then. 

There were no medical records for review that provided enough specific evidence to support that the patient only required 24 hour inpatient residential treatment or that the patient could not be treated in a less restrictive level of care then. There were no medical records reporting suicidal or homicidal ideation, plan, or intent, psychotic symptoms, self-injurious, aggressive, threatening, or severely agitated behavior, manic episodes, significant behavioral or mood symptoms requiring 24 hour treatment, or inability to care for the patient's basic needs. There were no reports of specific reported identifiable and quantifiable treatment goals that could only be achieved in a 24 hour residential treatment setting or that could not be achieved in a less restrictive setting or specific evidence that he was considered a danger to self or others. As a result, the recommendation is to uphold the previous decision and deny coverage for continued inpatient mental health residential treatment.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient.

The medical necessity for residential mental health treatment is not substantiated.