Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Major Depressive Disorder, Attention Deficit Hyperactivity Disorder (ADHD)

Treatment: Residential Mental Health Treatment for Children and Adolescents

The insurer denied the Residential Mental Health Treatment for Children and Adolescents. 

The denial was overturned.

This is a male patient who was admitted to this inpatient mental health residential treatment due to continued mood and behavioral symptoms putting him and others at risk of harm.  He was in a wilderness program and required this more intensive treatment in the residential treatment.  He had severe depressive symptoms including depressed mood, suicidal thoughts, self-harm behaviors, anxiety attacks, aggression, property destruction, poor emotional regulation, poor coping skills, low self-esteem, feelings of helplessness and worthlessness, obsessive compulsive symptoms, poor impulse control, poor attention, and social anxiety.  He had reportedly been using alcohol and cannabis.  He had a history of stealing, vandalizing, past suicide attempts by overdose and cutting, and had 2 past reported psychiatric hospitalizations.  He had diagnoses of Major Depressive Disorder, Attention Deficit Hyperactivity Disorder (ADHD), Social Anxiety Disorder, Obsessive Compulsive Disorder, and Body Dysmorphic Disorder.  He had reportedly taken medication including antidepressant medications, mood stabilizers, ADHD medications, anti-anxiety medications, and had individual, group, and family therapy.  He was discharged to a more intensive and higher level of care.

The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Suicidal Behaviors report that patients with past suicide attempts are at high risk for suicide and this patient had multiple past suicide attempts by serious methods including overdose and cutting and during the denial period still was making attempts to self-harm or suicide so he was at high risk for suicide.  It was reported according to notes he self-harmed, had property destruction, threatened his safety, ingested hand sanitizer to harm self, and he still had emotional dysregulation and poor coping skills.  It was reported that he locked himself in his room to inhale toxic vapors from substances that he stole from art class, tried to inebriate himself with hand sanitizer and rubbing alcohol, hid the containers, had a suicide notes, used his fingernails and objects to self-harm, was physically aggressive, emotionally dysregulating, tried to take a razor to self-harm, and he required physical restraints. He had an active treatment plan as he had reportedly taken medication including antidepressant medications, mood stabilizers, ADHD medications, anti-anxiety medications, individual, group, and family therapy.  This was a complex and high risk patient who required at least the intensive structured, supervised therapeutic mental health residential treatment in this setting.  He even tried suicide and self-harm attempts in this setting so he required an even higher level and intensity of treatment to better assure his safety and to try to improve emotional regulation and coping skills which is why he was discharged to a more intensive and higher level of care.  He was a high risk patient with severe depression and anxiety, poor impulse control, co-morbid alcohol and substance use, poor coping skills and emotional regulation who required at least 24 hour residential treatment. 

It did not appear that the health care plan acted reasonably, with sound clinical judgment, or in the best interests of the patient then.  

The carrier's denial of coverage for Residential Mental Health Treatment for Children and Adolescents is overturned.  The medical necessity is substantiated.