Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Mood disorder.
Treatment: Residential Behavioral Health Level of Care, Child or Adolescent.

The insurer denied the Residential Behavioral Health Level of Care, Child or Adolescent.  The denial is upheld.

The patient is a female. She was admitted to a behavioral health residential treatment level of care. She was reported to have been diagnosed with other psychotic disorder not due to substance or known physiological condition (F28) and mixed obsessional thoughts and acts (F42.2). The patient was also reported to have academic and educational problems (Z55.9). Other diagnoses indicated include disruptive mood dysregulation disorder (F34.81). She was reported to have been admitted for persistent symptoms of depression, anxiety and command auditory hallucinations telling her to kill herself. The patient was reported to have difficulties with attending school due to auditory hallucinations and anxiety. She was also reported to have frequent panic attacks, obsessive thoughts and compulsive behaviors.

The patient was not reported to have any significant history of behavioral health treatment in the past including inpatient psychiatric hospitalizations, residential treatment or day treatment in the past. She was reported to have been followed by an outpatient psychiatrist and therapist. There was no indication of the patient had any significant history of physical, emotional or sexual trauma. The patient was not reported to have any history of suicide attempts in the past. She was reported to have a history of urges to engage in self-injurious behaviors. There was no indication of the patient had exhibited any self-injurious behaviors including cutting. The patient was not reported to have any significant ongoing medical conditions that required interventions or monitoring. She was not reported to have any significant history of substance abuse. The patient was reported to have significant psychosocial stressors related to family conflicts.

The proposed treatment plan at the residential treatment of care included individual, group, and family therapy, in addition to medication management. The patient was noted to have been previously prescribed psychotropic medications including fluoxetine, methylphenidate and risperidone, in addition to medications for use as needed and ongoing medical conditions. Following admission, the patient was noted to have been prescribed psychotropic medications including fluoxetine, hydroxyzine, quetiapine and benztropine. Medications were noted to have been optimized for symptom control. The patient was not reported to have any significant adverse effects from any prescribed medication.

The clinical information reviewed indicates that the patient had no significant ongoing symptoms that required residential treatment level of care at the time of her admission. The patient was not reported to have any suicidal or homicidal ideations or deemed to be at risk of harm to self or others. She was noted to have auditory hallucinations. However, clinical evaluation indicated no evidence of any primary psychotic process. The patient was not reported to have any symptoms suggestive of delusions, or paranoia during her psychiatric evaluation. She was not reported to have any significant symptoms suggestive of mania or hypomania. She was not reported to have exhibited any significant and persistent agitation or aggressive behaviors. The patient was not reported to have engaged in any self-injurious behaviors recently and was not reported to have any significant urge.

No, the behavioral health residential treatment level of care was not found to be medically necessary.

Based on current evidence-based medical literature, the requested service (behavioral health residential treatment level of care was not found to be medically necessary. The clinical information provided does not indicate that the service requested was the least restrictive setting that was medically necessary or was likely to be successful in treating the patient's symptoms (1-9).

Treatment at a residential level of care with a 24-hour structured setting is required when there are significant safety concerns that require daily monitoring, significant functional impairments related to behavioral symptoms including impairments in self-care and activities of daily living, or significant substance use affecting daily functioning (1-9). Such symptoms include persistent low mood, agitation, aggression (1, 4, 7), persistent active suicidal ideations, symptoms of psychosis or mania, and continued substance use affecting physical and emotional health.

The clinical information reviewed indicates that the patient had no significant ongoing symptoms that required residential treatment level of care at the time of her admission. The patient was not reported to have any suicidal or homicidal ideations or deemed to be at risk of harm to self or others. She was noted to have auditory hallucinations. However, clinical evaluation indicated no evidence of any primary psychotic process. The patient was not reported to have any symptoms suggestive of delusions, or paranoia during her psychiatric evaluation. She was not reported to have any significant symptoms suggestive of mania or hypomania. She was not reported to have exhibited any significant and persistent agitation or aggressive behaviors. The patient was not reported to have engaged in any self-injurious behaviors recently and was not reported to have any significant urge.

Yes, the health plan acted reasonably and with sound medical judgment, and in the best interest of the patient.

The clinical information reviewed indicates that the patient had no significant ongoing symptoms that required residential treatment level of care at the time of her admission. The patient was not reported to have any suicidal or homicidal ideations or found to be at risk of harm to self or others. She was noted to have auditory hallucinations which appear to be largely related to significant anxiety. However, there was no indication that the patient was at risk of harm to herself or others. There was no indication of the patient exhibited any significant agitation or aggressive behaviors. She was not noted to have any significant ongoing medical conditions. There was no indication of the patient had any significant functional impairments that represented a change from her baseline. The patient may have been treated safely and effectively in a less restrictive setting and lower level of care. Therefore, the health plan was noted to have acted reasonably and with sound medical judgment, in the best interest of the patient.