Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Major Depressive Disorder

Treatment continued stay at residential behavioral health level of care, child or adolescent

The insurer denied coverage for continued stay at residential behavioral health level of care, child or adolescent

The denial is upheld

This female was admitted to inpatient residential treatment after a hospitalization due to suicidal ideation with plans and intent. She had reports of depressive and anxiety symptoms but no past reported suicide attempt. She had lack of motivation and energy, feelings of guilt, sleeping problems, and concentration problems. She reportedly was drinking alcohol every few weeks and using cannabis 3-4 times per week. She reportedly had past self-injurious behavior including cutting, skin picking, and pulling out eyelashes and eyebrows. She reportedly had past restricting eating behavior and body dysmorphia though denied eating disorder symptoms in months. She reportedly had attention problems and impulsivity. She had a past history of shoplifting and breaking rules as well as verbal aggression. She reportedly had past tactile hallucinations and panic attacks. She had diagnoses of Major Depressive Disorder, attention deficit hyperactivity disorder (ADHD), Generalized Anxiety Disorder, and Cannabis Use Disorder. She reportedly took Latuda and Gabapentin, and attended individual, group, and family therapy.
  
The American Academy of Child and Adolescent Psychiatry's Practice Parameter for the Assessment and Treatment of Children and Adolescents with Depressive Disorders provides that the decision for level of care will depend primarily on level of function and safety to self and others and also reports that the least restrictive level of care for safe and effective treatment is appropriate. In this case this patient initially presented with significant depressive symptoms and had a reported history of cannabis use, past eating disorder symptoms, and anxiety symptoms in addition to behavioral issues so she was recommended to a 24 hour residential treatment after a 24 hour hospital stay due to suicidal plans. She reportedly received pharmacotherapy, individual, group, and family therapy and improved. 

Notes from 2 days prior by the Psychiatrist reported that she had no mood swings, depression, suicidal or homicidal ideation, plan, or intent, hallucinations, paranoid ideation, had alright sleep and appetite, normal psychomotor activity, linear thought process, fair insight, judgment, and impulse control, and the recommendation was to continue her current medications. Other notes reported anxious mood but there were no reports of severe depression and anxiety or suicidal thoughts. Notes reported that she was engaged actively participating, had improved communication with her parents, and that she was able to discuss healthy lifestyle changes. 

Later, the medical records did not provide enough specific evidence to support that she only required 24-hour inpatient residential treatment or that she could not be treated in a less restrictive level of care. There were no reports of suicidal or homicidal ideation, plan, or intent, psychotic symptoms, self-injurious, aggressive, threatening, or severely agitated behavior, substance use, manic episodes, severe depression, or inability to care for his basic needs. There were of reports of specific 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 she was still considered a danger to self or others, and had no reports in the medical records provided that he had significant behavioral or mood symptoms requiring 24 hour treatment. As a result, the recommendation is to uphold the previous decision and deny continued inpatient residential treatment. It appeared that the health care plan acted reasonably, with sound medical judgment, and in the best interests of the patient then.

The insurer's denial of coverage for continued stay at residential behavioral health level of care, child or adolescent is upheld. Medical Necessity is not substantiated