Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Depressive disorder
Treatment: Inpatient psychiatric residential treatment center care
The insurer denied coverage for the inpatient psychiatric residential treatment center care.
The denial is upheld.

This young adult male was in treatment in a mental health residential treatment center due to depressive symptoms including depressed mood, tearfulness, thoughts of death though reports that he would not do anything to cause his death, decreased motivation, interest, and energy, apathy, difficulty concentrating and sleeping, isolation, appetite disturbance, and decline in academic and occupational functioning as he reportedly stopped attending college and was fired from employment. He reportedly was using cannabis and had a medicinal card. He reportedly tried cocaine, ketamine, psilocybin, and Adderall. He reportedly had hypervigilance and social anxiety. He reportedly was in past outpatient treatment for cognitive behavioral therapy (CBT) but not psychiatric treatment and had no past reported psychotropic medication trials. He reportedly lived with his parents and sister.

The Milliman Care Guidelines (MCG) Residential-Behavioral Health Level of Care- guidelines report that one needs to have continued danger to self or others, moderately or severe psychiatric or behavioral symptoms requiring 24 hour daily treatment, or serious dysfunction in daily living.

In this case this patient had reports of depressive symptoms but did not have reports of suicidal ideation, plan, or intent or evidence of danger to self or others or specific evidence that he only could be effectively treated in a 24 hour inpatient therapeutic mental health residential treatment then. It was reported that the patient had past outpatient mental health treatment with CBT but had no past psychotropic medication trials and was not in active outpatient psychiatric treatment, intensive outpatient mental health treatment or partial hospital program treatment which are less restrictive levels of care. There also were no reports that these levels of care would not likely be effective to treat this patient. The patient had reports of depressive symptoms and thoughts about death though reports that he would not do anything to cause his death and there was no reports of suicidal intent or plan. There were no reports of acute psychotic symptoms rendering him unable to care for basic needs. He had reports of psychiatric symptoms but there was no specific evidence to support that he only required 24 hour inpatient residential treatment. He reportedly was using cannabis though he had a medicinal card and had depressive symptoms, some trauma related issues and attention issues but he was not considered a current danger to self or others or unable to care for basic needs requiring 24 hour inpatient treatment. 

There were no medical records for review that provided enough specific evidence to support that he only required 24 hour inpatient residential treatment or that he could not be treated in a less restrictive level of care. There were no medical records reporting suicidal or homicidal ideation, plan, or intent, psychotic symptoms, self-injurious, aggressive, threatening, or severely agitated behavior, manic episodes, significant behavioral or mood symptoms requiring 24 hour treatment, or inability to care for basic needs. There were no reports of specific reported identifiable and quantifiable treatment goals that could only be achieved in a 24 hour residential treatment setting or that could not be achieved in a less restrictive setting or specific evidence that he was considered a danger to self or others. 

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for psychiatric residential treatment center care is not substantiated.