Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Depressive Disorder.
Treatment: Residential mental health treatment .
The insurer denied residential mental health treatment.
The determination is upheld.

The patient was admitted for residential mental health treatment to address recurrent and moderately severe major depressive disorder with a decline in functioning and alcohol use that was moderate. The patient presented with symptoms of depression, anxiety, and affective instability together with functional impairment resulting in the referral and admission to residential level treatment. He had severe psychosocial stressors and grief related to the death of his father, a pending divorce and his mother's diagnosis with terminal stomach cancer.
Initial evaluation revealed a mental status examination with severe psychiatric symptoms that included depression with hopelessness and passive thoughts of death. He did not display symptoms of mood cycling or mania, thought disorder, severe cognitive impairment or homicidal ideation. He denied active suicidal ideation, plan or intent. He was noted to be calm with an anxious demeanor that included dysphoric mood, and fair insight with intact judgment and cognition. He had disturbed sleep and daytime fatigue.
The patient had no acute general medical conditions or other substance use disorders. Medical screening was negative or normal with regard to examination and laboratory assessments except for a fatty liver. He was diagnosed with Wolf Parkinson White syndrome and sleep apnea.
The patient is supported in his treatment effort by family-his mother and sister. As noted, he was married with a pending divorce. He has two children with his wife. He was well-educated and employed. There was no trauma history or legal issues in this case.
The residential treatment focused on mood stabilization and communication within the family, as well as other services to address life skills, coping, and peer relationships. Residential structure and monitoring and programming were provided, and initially, the treatment plan included safety monitoring with suicide precautions. Individual, group and activity therapies were provided along with family conferences and therapeutic interventions to address grief, affective instability and substance use.
The treatment and clinical course including documentation with therapy and progress notes depicted good relations with staff and peers despite a tendency to not follow rules. The patient continued with active participation in treatment that included group and individual sessions together with other interventions within the residential setting, and discharge planning, as well as safety checks. He was prescribed Abilify, Lexapro and gabapentin initially with discontinuation of Ability and the addition of Wellbutrin, titrated as clinically appropriate. Additionally, he received trazodone for sleep and modafinil to address daytime fatigue. His clinical course remained uncomplicated with improved mood and diminished anxiety. He was discharged from residential care with recommendations for continued medication management and intensive outpatient level care with group dialectical behavior therapy (DBT).
At issue is the medical necessity of residential mental health treatment.
The requested health service/treatment of residential mental health treatment is not medically necessary for this patient.
Continued Residential Mental Health Treatment is not considered clinically appropriate and was not medically necessary in this case scenario. The patient's symptoms depression and anxiety were amenable to treatment with lower-level services in a less restrictive environment with intensive services including therapeutic interventions to address the recent use of alcohol. Continued treatment could have been effectively provided in a less restrictive treatment setting with evidence based psychosocial treatments and continued medication management. The psychosocial stressors were not so severe to prevent ongoing assessment and treatment at a lower level of care in this case scenario. Moreover, there were no general medical issues that were a focus of treatment, and no other clinical features that would have warranted the continued residential level treatment in this case scenario. The patient has family support and access to mental health and substance use disorder treatment and services in the community that further supports that the services were not medically necessary.
This answer is consistent with prevailing standards of medical practice, and with the scientific literature, referenced below, as well as New York State instruction for this review including the application of NY State Office of Alcoholism and Substance Abuse Services (OASAS) Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) 3 Criteria.