Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Mental health
Secondary: PTSD
Treatment: Mental Health Residential
The patient is receiving residential level mental health treatment to address an unspecified schizophrenia spectrum disorder and co-morbid persistent depressive disorder, attention deficit hyperactivity disorder-predominantly inattentive type, chronic posttraumatic stress disorder resulting from a sexual assault, and, an unspecified personality disorder with borderline and narcissistic traits. The patient was initially admitted in the context of severe psychosocial stressors including the terminal illness and demise of her mother, and ongoing family stress associated with the patient's affective and psychotic disturbances. The patient has prominent symptoms related to multiple past trauma, as well as the stress with her mother's terminal illness that triggers  symptoms with contact. The patient was admitted to residential level treatment with step down to extended residential level care with plans for continued intensive treatment together with the structure and monitoring of a residential level service.
The patient has no acute general medical issues or substance-related problems. The patient underwent comprehensive medical and psychiatric evaluation at the time of admission to the program with plans for evidence-based therapeutic interventions to improve coping skills and address core symptoms of trauma-related and mood and psychotic disorders together with therapeutic interventions to address the personality disorder and characterological defects. The treatment plan included the goals of improved coping; breaking the cycle of self-destructive behaviors; and, the development of healthy relationships. Individual, group and activity therapies and family focused sessions are provided, as clinically appropriate. During the dates in question the patient actively participated in the treatment plan and was engaged in therapeutic interventions in the context of a residential program with structure, intensive treatment, and social supports. The treatment course and case records/notes and updates reflect engagement with the treatment plan, but continued bouts of anxiety and anger and continued daydreaming. The patient has made unsteady progress in the past that slowly resulted in improved functioning despite continued symptoms of the mood and personality and chronic psychotic disorder. Therapeutic interventions were continued with appropriate monitoring including the use of bupropion and Vyvanse and melatonin to address symptoms of depression, the ADHD and sleep disturbance. The health plan's determination of medical necessity is upheld. The patient's continued residential level treatment is not reasonable or in the best interest of the patient; patient had no safety concerns, and no symptoms associated with the comorbid conditions that would have warranted continued residential level services. Despite unsteady progress, the patient readily engaged in treatment and the intermittent bouts of affective instability did not require residential level structure or monitoring. The treatments to address maladaptive coping, distress problems, interpersonal functioning problems and day-to-day functioning problems were amenable to treatment at a lower level of care. The monitoring, structure and intensity of residential services were not medically necessary in order to continue the management of this patient's mental disorders.