Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Autism Spectrum

Treatment: Continued residential mental health treatment

The insurer denied coverage for continued residential mental health treatment.

The denial is overturned.

This is the case of a female to male transgender patient who was admitted to this inpatient mental health residential treatment due to severe emotional dysregulation, physically aggressive behavior, poor anger and impulse control, depression, anxiety, and school refusal. The patient also reportedly had developmental delays in social interaction and had a diagnosis of autism spectrum. The patient also had a diagnosis of attention deficit hyperactivity disorder (ADHD), gender dysphoria, major depressive disorder, and learning disorder. It was reported that the patient had multiple therapeutic inpatient residential treatments and psychiatric hospitalizations. It was reported that the patient had been receiving therapeutic services at an early age and under psychiatric care. The patient reportedly attended group, individual, and family therapy, and had pharmacotherapy. The patient was discharged with the recommendation to continue residential treatment.
    
The American Academy of Child and Adolescent Psychiatry (AACAP) Practice Parameters for the Assessment and Treatment of Children, Adolescents, and Adults with Autism and Other Pervasive Developmental Disorders reports that patients with severe behavioral problems including aggression and self-injurious behaviors that cannot be managed in an outpatient setting are candidates for inpatient treatment and that the least restrictive level of care for safe and effective treatment is appropriate. 

It was reported that this patient had emotional dysregulation, poor anger and behavior control, physical aggression when not in a 24-hour inpatient setting, and even had physical aggression while in a 24-hour therapeutic residential school requiring being restrained, had developmental delays in social interaction, social and emotional reciprocity, had interpersonal struggles, cognitive rigidity, emotional reactivity, isolation, school refusal, emotional and behavioral instability, lack of insight, depression, loneliness, gender dysphoria issues, and difficulty with activities of daily living (ADLs). The patient had significant psychiatric issues and was complex due to her developmental delays and gender dysphoria issues. The patient reportedly had 4 different therapeutic residential treatments in 4 different states and had 3 psychiatric hospitalizations as well. The patient had reports of physically aggressive behaviors while in a therapeutic residential school requiring the patient being restrained. This patient reportedly had the first psychiatric hospitalization after an aggressive act at a residential school and this pattern repeated at the next 2 residential schools. The patient needed a thorough evaluation and treatment following the physically aggressive act. It was necessary for the patient to complete the treatment in this inpatient mental health residential treatment setting before attending another facility to complete education and treatment. The patient was recommended for further inpatient mental health residential treatment following this discharge and it was reported that it should include continued involvement in individual, group, and family therapy, as well as pharmacotherapy. It was reported that additional emphasis should be placed on helping cultivate daily living, social/interpersonal and emotional regulation skill sets, support academically, and ongoing psychiatric services. Without this 24-hour structured and supervised therapeutic residential inpatient mental health setting the patient likely would regress in behaviors and symptoms and regress socially and ability to care for self and basic needs and would be more at risk for danger to self and others due to poor impulse and anger control and past aggressive behaviors. 

Continued inpatient mental health residential treatment was medically necessary as the medical records provided enough specific evidence to support that the patient required 24-hour residential treatment.  It did not appear that the health care plan acted reasonably or in the best interests of the patient.

The insurer's denial of coverage for continued residential mental health treatment is overturned. Medical necessity is substantiated.