Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Major Depressive Disorder.
Treatment: Admission for residential mental health treatment.

The insurer denied coverage for admission for residential mental health treatment.
The denial is overturned.

This is the case of a male who was transferred from another residential treatment facility due to high risk of harm to self and others, continued mood symptoms, and poor functioning including inability to function adequately at home or in the community. He had depressed mood, isolation, crying, decreased energy, poor activities of daily living (ADLs), impulsive behavior, and social delays. He reportedly had multiple past serious suicide attempts including stabbing self and 2 carbon monoxide poisoning attempts while drinking. He reportedly also stabbed and cut himself in the wrists and arms and also attacked his roommate at college while he was sleeping and stabbed him with a knife in the throat just missing his artery. He reportedly had a diagnosis of Major Depressive Disorder, Social Pragmatic Disorder, and Substance Use Disorder. He reportedly had social delays and there was question about a possible diagnosis of Autism Spectrum Disorder. He reportedly was taking Wellbutrin, Lithium, Abilify, Zoloft, Cytomel, and Melatonin. He reportedly had past residential treatment 6 months, and also was in a boarding school. It was reported that he stabbed his roommate in the neck almost killing him and then stabbed himself in the wrists and arms. He reportedly went to the psychiatric hospital after that and was discharged and then sent to residential treatment. He reportedly is still in residential treatment. 
    
The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Major Depressive Disorders reports that the least restrictive level of care for safe and effective treatment is appropriate. The MCG (Milliman Care Guidelines) Residential-Behavioral Health Level of Care- Psychiatry guidelines report that one needs to have continued danger to self or others, moderate or severe psychiatric or behavioral symptoms requiring 24-hour daily treatment, or serious dysfunction in daily living. For discharge it states that there needs to be sufficient support at a lower level of care, absence of suicidal or homicidal thoughts or thoughts of harm to self or others. 

In this case, the patient continued to have moderate-severe psychiatric symptoms and was considered at risk to self and others if discharged from a 24-hour therapeutic supervised and structured residential treatment setting. He still did not have adequate enough coping skills to function safely outside of this residential treatment setting. In this case this was a high-risk patient with poor coping skills and poor insight with developmental delays who had depressive symptoms, past serious dangerous behavior to others and self, multiple past suicide attempts who still did not have the necessary coping skills to function so he required continued 24 hour therapeutic residential treatment. 

He required a substantial amount of time in this setting. It was reported that he changed insurance and that that insurer approved mental health residential treatment. He was considered a high-risk patient in need of 24-hour mental health residential treatment. 

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

The insurer's denial of coverage for an admission for residential mental health treatment, revenue code 1001 is overturned. Medical Necessity is substantiated.