Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Major Depressive Disorder.
Treatment: Mental health residential level of care.

The insurer denied the mental health residential level of care.  The health plan's determination is overturned.

The patient is a female, who was referred for residential mental health treatment in an outdoor wilderness-based program in order to address behavioral disturbances in the context of mood, anxiety, attentional, and neurodevelopmental disorders associated with impaired functioning and problematic behavior. The patient was diagnosed with major depressive disorder, social anxiety disorder, attention deficit hyperactivity disorder-inattentive type, and an unspecified developmental disorder. The patient's presenting issues included low self-esteem, lack of confidence, and relationship problems together with stressors within the primary support, educational and social environment domains. The patient had been in past treatment settings but failed to engage with treatment with continued symptoms of depression and anxiety together with a history of social withdrawal, school failure/refusal, and mood instability associated with substance use with cannabis-vaping alone with social isolation and refusal to communicate with parents or leave her bedroom. The patient was referred to the residential treatment in an outdoor/wilderness setting in order to address the core symptoms of depression and relationship problems including parent-child relational problems and a lack of motivation.
The patient has a history of outpatient treatments without sustained benefit. There has not been a suicide attempt, or violent or aggressive behavior or impulse control problems. However, the patient has conflict with her parents that did include lack of motivation and problematic behavioral disruptions that included the school refusal, problems with peers, family conflict, uncooperative behavior, social isolation and refusal to communicate.

The program focused on organizational skills; self-care; peer relationships; and other life skills, as well as behavioral and emotional regulation with milieu, individual, group, family, and outdoor therapies/sport, as well as other interventions aimed at improving life skills. The patient actively participated in the treatment plan and worked on therapeutic, social, and emotional functions in the context of a therapeutic milieu with a residential level of structure and monitoring in a behavioral health program and setting that included educational assignments and psychiatric services with availability of ongoing medication management. 

The patient's admission and continued residential level treatment through discharge is reasonable and in the best interest of the patient; she continued to display clinical features and symptoms that necessitated the admission and the continued residential level services, as she struggled to engage in treatment and had intermittent bouts of affective instability that did require residential level structure and monitoring with active treatment. She had a history of treatment failure with lower-level services and had recently displayed significant problematic behaviors with maladaptive coping, emotional regulation problems, distress problems, interpersonal functioning problems and day-to-day functioning problems that included school refusal in the context of severe mood and anxiety disorders complicated by attention deficit hyperactivity disorder (ADHD)-inattentive type and a neurodevelopmental disorder, as well as vaping cannabis class substances in isolation. The treatment provided was evidence-based and medically necessary and appropriate and could not have been effectively provided in a less restrictive treatment environment through discharge. 

The health plan's determination of medical necessity is overturned.