Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Oppositional defiant disorder (ODD), Attention-deficit/hyperactivity disorder (ADHD), Reactive attachment disorder (RAD), Substance use disorder
Treatment: Continued mental health residential treatment
The insurer denied coverage for continued mental health residential treatment.
The denial is upheld.

This is a male child who was admitted to mental health residential treatment due to oppositional defiant disorder (ODD), attention-deficit/hyperactivity disorder (ADHD), reactive attachment disorder (RAD) of childhood, and cannabis use disorder. The patient refused psychotropic medications but had group therapy as well as dialectical behavior therapy (DBT) and cognitive behavioral therapy (CBT), and family work. The patient was discharged after 87 days. The insurer denied coverage for days 79 through 87.
  
The American Academy of Child and Adolescent Psychiatry (AACAP) Practice Parameters for the Assessment and Treatment of Children, Adolescents, and Adults with Oppositional Defiant Behaviors reports that in considering the intensity of medically necessary services one needs to assess the severity of the problems, appropriate intensity of services, and provide the least restrictive or intrusive services necessary. In this case, this patient reportedly was admitted to this facility due to past behavioral symptoms, cannabis use, and interpersonal issues. However as of day 79, documentation did not report further severe symptoms that required 24-hour treatment. 

Notes on day 79 reported that the patient had euthymic mood, denied suicidal or homicidal ideation, and had appropriate affect, normal speech, and clear thought process, with no hallucinations. The patient was noted to be cooperative, an active participant, and encouraged positive peer behaviors. Notes 2 days prior to discharge reported that the patient was making progress, was working on goals of healthy lifestyle skills, peer relationships, working on a schedule for home, working on coping skills, and activities of daily living (ADLs). The patient was noted to be open and engaged, future-oriented, at baseline, and free from urges to use substances. Notes on the day prior to discharge reported that the patient had good mood, coherent thought process, denied suicidal or homicidal ideation, had no hallucinations, and there were no reports of severe psychiatric symptoms. 

As of day 79, there were no reports of specific identifiable or quantifiable treatment goals or objectives that could only be achieved in a 24-hour residential treatment or that could not have been achieved in a less restrictive setting then. Also as of day 78, there was no specific evidence that the patient was a danger to self or others that required 24-hour mental health treatment, and there were no reports of severe mood symptoms, behavioral problems, psychotic symptoms, suicidal or homicidal ideation, plan, or intent, acute substance use issues, or other severe psychiatric symptoms. Thus, continued mental health residential treatment from days 79 through 87 was not medically necessary for this patient.

The health plan acted reasonably with sound medical judgment and in the best interest of the patient.

Based on the above, the medical necessity for mental health residential treatment as of day 79 of treatment going forward is not substantiated. The insurer's denial should be upheld.