Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Major Depressive Disorder-severe-recurrent. 
Treatment: Continued stay at an acute mental health inpatient level of care. 

The insurer denied coverage for continued stay at an acute mental health inpatient level of care. 

The denial is overturned. 

This teenage male was admitted to this inpatient mental health residential treatment after a psychiatric hospitalization due to a suicide attempt by cutting himself. He had major depressive symptoms including suicidal intent, plans, behaviors, depressed mood, emotional dysregulation, feelings of hopelessness, anxiety symptoms, delays in social interaction and communication and in social relationships. He reportedly had difficulties with affect regulation, relationship difficulties, academic difficulties, and also substance use issues including alcohol and cannabis use. The patient had diagnoses of Major Depressive Disorder-severe-recurrent, Autism Spectrum Disorder, Generalized Anxiety Disorder, and attention deficit hyperactivity disorder (ADHD). He reportedly had past other inpatient treatments following a serious suicide attempt by overdose of 50 Tylenol pills and Aleve with a large amount of vodka which resulted in a psychiatric hospitalization. He reportedly was in a wilderness program. He then went to a boarding school due to more hopelessness and self-injurious behavior by cutting self. He also went to the Emergency Room (ER) for another suicide attempt by cutting. He was in psychiatric hospitalization and then went residential treatment, a mental health residential treatment. 
    
The American Psychological 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 APA Practice Guidelines for the Treatment of Patients with Suicidal Behaviors reports that patients with past suicide attempts are at high risk for suicide. 

This patient had 2 past suicide attempts by overdose resulting in hospitalizations. He was considered a high-risk patient with difficulty in coping skills and had multiple psychiatric problems and multiple past suicide attempts with continued suicidal plan and intent and depressive symptoms. This supervised and structured 24-hour inpatient therapeutic residential treatment setting was considered still medically necessary treatment during the denial period. 

It did not appear that the health care plan acted reasonably, with sound clinical judgment, or in the best interests of the patient. 

The medical records provided enough evidence to support that he required this level of care. This was a very high-risk patient with multiple past suicide attempts who still reported suicidal intent and made threatening suicidal statements such as he will sign out of this facility and then kill himself. He continued to report depressive symptoms including depressed mood and hopelessness during the denial period while still struggling with social interactions, relationships, and communication. 

The insurer's denial of coverage for the continued stay at an acute mental health inpatient level of care is overturned. Medical necessity is substantiated.