Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Mental Health. 
Treatment: Mental Health In-Patient. 
The insurer denied Residential Treatment Center (RTC) Mental Health Services. 
The denial was upheld in whole.

The patient is an emerging adult female to male who presented for residential level treatment of a severe mood disorder with borderline personality traits complicated with a history of suicidal and a remote history of self-harming behavior and problematic behaviors related to the borderline personality. The patient did not have a diagnosis of co-occurring substance use disorder or acute general medical issues though she did have a diagnosis of scoliosis and past orthopedic problems. Her symptoms of mood disturbance were associated with chronic suicidal behavior for which she had been hospitalized multiple times followed by outpatient treatment with medication and therapy. She had received multiple medication trials and varying levels of treatment without sustained benefit or a remission of symptoms. More recently, she had attempted suicide earlier in the year with subsequent leave from college and return home where she was monitored by her family. She was subsequently referred to the residential treatment facility with admission. The patient's presenting clinical features prompted the referral to residential treatment to address the psychosocial issues and behavioral disturbances associated with the mood and personality disorder. Her referral for residential treatment was also prompted by her clinical providers with safety concerns and the persistent depressive disorder and recurrent episodes of major depression. Thus, the patient was admitted to residential level care in the context of worsening symptoms of mood disturbance with chronic suicidal and self-destructive behaviors associated with poor control of impulses together with maladaptive coping and emotional dysregulation. Evaluation on admission revealed a mental status examination with severe psychiatric symptoms in the context of chronic depressive disorder (dysthymic disorder or persistent depressive disorder) associated with severe and recurrent major depressive disorder and the personality disorder. The patient was cooperative with evaluation. There was no acute suicidal ideation, but she had reported suicidal behaviors and attempts, as well as a history of self-harm. There was no evidence of frank psychosis, mania, thought disorder, or severe cognitive impairment. Insight was limited. The patient is single and a college student; she is characterized as a good student. There are no prominent family problems, but the patient has relationship problems, but no specified trauma history or legal problems. She reports being bullied in high school. Throughout the residential stay, the patient was engaged in therapy and participating in sessions to address the mood and personality disturbance. The health plan's determination of medical necessity is upheld. The requested health service/treatment of Residential Treatment Center (RTC) Mental Health Services was not medically necessary for this patient. The health plan's decision to deny coverage for the requested residential treatment is reasonable in this case scenario. The patient was cooperative and motivated to engage in treatment. The patient had no complicating general medical or clinical or psychiatric features that would necessitate 24-hour monitoring or residential level of care. The patient did not exhibit aggressive or impulsive behaviors and denied suicidal plan or intent of self-harm. Her suicidal ideation was chronic in nature and the patient was capable of engaging in treatment in a less restrictive treatment setting. She was compliant with the treatment plan and adherent with medications and attending to daily activities and attending groups and other therapeutic activities. Participation in treatment at a lower level of care was reasonable and was in the patient's best interest in this case scenario.