Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Mood disorders and substance abuse 
Treatment: Mental health residential treatment 
The insurer is denied coverage for the mental health residential treatment. 
The denial is upheld. 

This was then a female who was admitted to the mental health residential treatment due to mood and anxiety symptoms, emotional dysregulation, and substance use. The patient was using cannabis daily, cocaine every other day, alcohol and sedative hypnotics socially, and she had reports of panic attacks, yelling and crying. During inpatient stay, the patient took Prozac and Abilify, attended individual, group, and family therapy. The patient was then discharged. 

The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Substance Use Disorders states that residential treatment is indicated primarily for individuals who do not meet clinical criteria for hospitalization but whose lives and social interactions have come to focus exclusively on substance use and who currently lack sufficient motivation and/or substance-free social supports to remain abstinent in an ambulatory setting. In this case, this patient had residential treatment and was approved for treatment. During this time, the patient made clinical progress. The chart notes provided forward did not provide further specific evidence to support that this patient could only be treated in this level of care as of then. There were no reported specific identifiable or quantifiable treatment goals or objectives that could only be achieved in a 24-hour residential setting then or that could not be achieved in a less restrictive setting then. 

Notes reported that the patient had rising self-esteem, was appropriate during group therapy, had good insight, had fair judgment, and had good mood, sleep, and appetite; the patient had no hallucinations, and denied cravings or urges for substance use, and denied suicidal or homicidal ideation. Notes reported that the patient continued to deny suicidal/homicidal ideation and hallucinations, and had good mood. Notes reported that the patient had good mood, clear and relevant thoughts, no hallucinations, denied cravings or urges, had no major impulse control issues, and she denied suicidal or homicidal ideation, was insightful; the patient was ready for Intensive Outpatient Program (IOP) transition. The patient was discharged. 

The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Major Depressive Disorder reports that patient with suicidal intent or plan, or behaviors, or who present as a danger to self or others or who have self-injurious behavior or suicidal thoughts or behaviors are in need of inpatient treatment. In this case, this patient clinically improved from her admission presentation and did not have reports of severe depressive symptoms, suicidal ideation, intent, or plan, or inability to care for his basic needs. Thus, continued mental health residential treatment was not medically necessary to treat this patient's medical condition. 

The health plan acted reasonably with sound medical judgment, and in the best interest of the patient. 

The carrier's denial of coverage for the mental health residential treatment should be upheld. The medical necessity is not substantiated.