Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Schizoaffective Disorder Bipolar Type (hallucinations or delusions with mood changes) and Generalized Anxiety Disorder
Treatment: Continued Residential Treatment Level of Care stay
The insurer denied the Continued Residential Treatment Level of Care stay.
The denial is partially overturned.

The patient is an adult male. He has a chronic psychotic disorder best characterized as schizoaffective disorder, bipolar type. The patient had co-occurring substance use disorder with recent use of cannabis that was mild. There was a past history of use of other substances of abuse including MDMA (Ecstasy) and cocaine. The patient is diagnosed with co-morbid generalized anxiety disorder.

The patient presented for residential treatment due to persistent symptoms of anxiety, depression with ruminations, and guilt and shame regarding his sexual behavior that had been problematic. Despite extensive outpatient level treatments, the patient had deteriorated in the context of a mood disturbance and cognitive decline associated with the schizoaffective disorder. The exacerbation of the psychotic and mood disorder resulted in significant consequences with regard to family, social, and occupational functioning and relationships, as well as his own identity despite having family support and being well-educated.

The patient's mental status examination at the time of presentation for residential level services revealed dysphoric mood with sad and anxious affect and disorganized thought processing that included poor executive functioning with regard to decision-making, organizing, and problem solving. He had a history of markedly impaired judgment related to his sexuality together with limited insight and poor impulse control. At the time of admission for residential level treatment, the patient had no evidence of psychosis (delusions or hallucinations), mania, or other symptoms reflecting bipolar disorder. He denied suicidal ideation or intent despite the depressive ruminations with shame, guilt, and a profound sense of hopelessness. Concentration was impaired and volition and motivation were diminished, impacting his ability to function.

The patient has a past treatment history for mood and psychotic disorder; he had multiple prior psychiatric hospitalizations but no history of suicide attempt. He was prescribed antipsychotic medications and mood stabilizers including the use of Depakote, Seroquel, and propranolol.

There were no acute general medical conditions. The patient had a history of concussion and chronic back pain with possible traumatic brain injury related to a motor vehicle accident. He reported 85 pounds of weight gain over 12 months.

The patient is well-educated, single, and unemployed, with past work as an attorney. There is a possible history of trauma or abuse in this case. The patient had severe impairment of functioning with stressors involving occupational and other psychosocial domains.

The patient was admitted to residential services with safety monitoring, structured psychosocial programming, and resumption of pharmacotherapy. His clinical course was complicated by severe symptoms of mood and anxiety that persisted with modest progress. Adjustment of the patient's medications had occurred as clinically appropriate with a regimen of Lamictal, Seroquel, and Vyvanse, and a tapering of the Depakote. He had lost weight and was feeling better with regard to his general health; laboratory assessment was normal or unremarkable. He was receiving treatment for the back pain including ablation therapy. The patient's adherence with medications was variable and uneven.

The patient was noted to have made gains with therapy including family focused sessions and he displayed improvement with clearer thinking and improved concentration. He continued to have anxiety, depression, and hopelessness with shame, guilt, and ruminations with regard to past behavior and his current circumstances. However, the patient has made significant progress and was more hopeful and forward-looking with regard to prospects for the future. He had stopped family focused sessions and was more optimistic in his thinking. He continued to deny suicidal ideation or intent and his mood was not cycling. Thought was disorganized with improved ability to think. concentrate, and execute his functions. The treatment team was planning for continued and extended residential treatment going forward as indicated by the submitted documentation that revealed engagement in treatment, no safety concerns, and improved function while working to address struggles with identity and relationships including intimacy.

The Continued Residential Treatment Level of Care stay was medically necessary, in part.

Specifically, for the first part of the residential stay, the requested health service was medically necessary. However, for the second part of the residential stay, the requested health service was not medically necessary for this patient.

In accordance with prevailing standards of medical practice and the NY (New York) State instruction for review, the patient did require the continued structure, monitoring, and treatment with residential level of care during the interval under review in order to administer the continued treatment for the psychiatric disturbance in this case while conducting ongoing evaluations and observing the patient's functioning with intense therapy and monitoring for response to medications that had been adjusted accordingly. It was medically necessary for this patient to continue with 24-hour monitoring and remain in residential level structure in view of the persistent symptoms of chronic psychosis and mood disturbance, the continued disturbance of thought with depressive ruminations, guilt, shame, and hopelessness that represented a safety risk, as well as high risk for relapse with co-occurring substance use disorder and impulsive and inappropriate sexual behavior. Additionally, the residential stay during this time interval was medically necessary in order to monitor the response to medications as noted, especially in view of a recent history of multiple past hospitalizations together with limited insight and judgment, and substance abuse while receiving outpatient services prior to his referral to residential treatment.

However, the continued residential level treatment beyond a certain point was not medically necessary in this case. The patient had made progress with the treatment, and was noted to be functioning better with more optimism, clearer thinking and concentration and completion of family-focused sessions, all of which were indicative of the patient's ability to continue treatment in a less restrictive treatment setting. The patient could have been effectively managed with lower-level care based upon the submitted documentation and in keeping with prevailing standards of medical practice and published guidelines pertaining to appropriate levels of care. There were no remaining treatment issues or clinical features that would have required the continued residential level services, structure, or monitoring.

This answer is consistent with prevailing standards of professional practice, and with the published practice guidelines, referenced below.