Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Major Depressive Disorder and Generalized. Anxiety Disorder.
Treatment: Continued Inpatient Behavioral Health Services.
The insurer denied the Continued Inpatient Behavioral Health Services.
The denial is upheld.

The patient is a female who was admitted to a behavioral health residential treatment level of care. She was reported to have been diagnosed with major depressive disorder, recurrent, moderate (F33.1), generalized anxiety disorder (F41.1) and attention deficit hyperactivity disorder, predominantly inattentive type (F90.0). Other diagnoses indicated include: B personality traits, high expressed emotion level and parent-child relational problem. She was reported to have been admitted to the residential treatment level of care in order to address symptoms of depression, anxiety, sexual promiscuity, academic disengagement, under performance, and difficulties with emotional regulation. The patient was also reported to have significant conflicts with her family and inappropriate use of social media. The patient was reported to have been admitted to an acute inpatient psychiatric unit for suicidal ideations with a plan. She was noted to have been subsequently stepped down to a residential treatment level of care. She was reported to have a history of prior suicide attempts.

The clinical information reviewed indicates that the patient had no significant ongoing symptoms that required a 24-hour structured setting for treatment.  The patient was not reported to have any suicidal or homicidal ideations or deemed to be at risk of harm to self or others at the time of her admission. She was not reported to have any symptoms suggestive of psychosis including hallucinations, delusions, or paranoia. She was not reported to have any significant symptoms suggestive of mania or hypomania. She was not reported to have exhibited any significant and persistent agitation or aggressive behaviors. The patient was not reported to have engaged in any self-injurious behaviors recently and was not reported to have any significant urge. 

The patient was not reported to have any significant worsening or emergence of new symptoms throughout her stay at the residential treatment level of care. The patient was not reported to have any significant ongoing medical conditions that required interventions or monitoring. She was not reported to have any significant adverse effects from any prescribed medications. She was not reported to have significant functional impairments including age-appropriate activities of daily living or self-care. There was no indication that the patient had any significant barriers to continuing treatment in the community including severe psychosocial stressors, lack of social support or unsafe living environment. The patient was noted to have been discharged to continue outpatient treatment.

No. The proposed treatment was not found to be medically necessary.
Based on current evidence-based medical literature, the requested service (behavioral health residential treatment) was not found to be medically necessary. The clinical information provided does not indicate that the service requested was the least restrictive setting that was medically necessary or was likely to be successful in treating the patient's symptoms. 

Treatment at a residential level of care with a 24-hour structured setting is required when there are significant safety concerns that require daily monitoring, significant functional impairments related to behavioral symptoms including impairments in self-care and activities of daily living, or significant substance use affecting daily functioning (1-9). Such symptoms include persistent low mood, agitation, aggression (1, 4, 7), persistent active suicidal ideations, symptoms of psychosis or mania, and continued substance use affecting physical and emotional health.

The clinical information reviewed indicates that the patient had no significant ongoing symptoms that required residential treatment level of care. The patient was not reported to have any suicidal or homicidal ideations or deemed to be at risk of harm to self or others at the time of her admission. She was not reported to have any symptoms suggestive of psychosis including hallucinations, delusions, or paranoia. She was not reported to have any significant symptoms suggestive of mania or hypomania. She was not reported to have exhibited any significant and persistent agitation or aggressive behaviors. The patient was not reported to have engaged in any self-injurious behaviors recently and was not reported to have any significant urge. 

The patient was not reported to have any significant worsening or emergence of new symptoms throughout her stay at the residential treatment level of care. The patient was not reported to have any significant ongoing medical conditions that required interventions or monitoring. She was not reported to have any significant adverse effects from any prescribed medications. She was not reported to have significant functional impairments including age-appropriate activities of daily living or self-care. There was no indication of the patient had any significant barriers to continuing treatment in the community including severe psychosocial stressors, lack of social support or unsafe living environment. The patient may have been treated safely and effectively in a less restrictive setting and lower level of care such as a partial hospitalization program. The interventions proposed for the patient may have been provided safely and effectively in a day treatment setting.

Yes. The health plan was noted to have acted reasonably, with sound medical judgment and in the best interest of the patient.
Clinical information provided does not indicate that the patient required a 24-hour structured setting for continued treatment of her symptoms at the time of her admission to the behavioral health residential treatment level of care. There was no indication of the patient was at immediate danger outside of a residential treatment level of care. She was not reported to have any suicidal or homicidal thoughts, plans or intent. There was no indication of the patient had any symptoms suggestive of psychosis or mania. She was not reported to have any significant ongoing medical conditions that required interventions or monitoring. The patient was not reported to have any significant adverse effects from any prescribed medications. There was no indication of the patient had any significant functional impairments including age-appropriate activities of daily living or self-care that represented a change from her baseline. 

Clinical information provided does not indicate that the patient had any significant barriers to treatment in the community including severe psychosocial stressors, unsafe living environment or lack of social support. The patient may have been treated safely and effectively in a less restrictive setting and lower level of care such as a partial hospitalization program. Therefore, the health plan was noted to have acted reasonably, with sound medical judgment and in the best interest of the patient.