Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Depression and suicidal plans

Treatment: inpatient mental health residential treatment. 

The insurer denied coverage for inpatient mental health residential treatment. The denial was reversed.

This patient is a female child who was admitted to this inpatient mental health residential treatment after two recent psychiatric hospitalizations for depression and suicidal plans. It was reported that she was psychiatrically hospitalized in mid- 2018 and again several weeks later. It was reported that her depression worsened, including an inability to get out of bed and not eating or showering. She had multiple suicidal plans, including overdose and strangling herself and had recent text messages to an ex-girlfriend about a plan for suicide with a knife. She was not able to contract for safety then. It was recommended upon discharge from her last psychiatric hospitalization that she attend a supervised and structured therapeutic inpatient mental health residential treatment to try to improve coping and problems solving skills, better deal with regulating her emotions and not acting out her negative emotions and depression in a self-destructive way. She had past reports of self-injurious behavior, including cutting herself. She reported social anxiety, isolation and loneliness and was feeling overwhelmed. She had diagnoses of Major Depressive Disorder and Borderline Personality Disorder. She attended individual, group and family therapy and was discharged.

The insurer denied coverage for inpatient mental health residential treatment as not medically necessary treatment. They stated that she did not require 24-hour treatment then, and they recommended a less restrictive level of care.

This reviewer disagrees with the decision to deny coverage for inpatient mental health residential treatment as the chart notes provided enough specific evidence to support that she required this 24-hour supervised and structured therapeutic inpatient mental health residential treatment. 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. 

In this case, this patient was considered to be a potential danger to self if not in a 24-hour supervised and structured therapeutic inpatient mental health residential treatment, as she had two recent psychiatric hospitalizations for worsened depression with multiple suicidal plans; therefore, she was considered a high risk patient. She had poor coping and problem solving skills and difficulty regulating her emotions. It was reported that she needed this supervised and structured therapeutic inpatient mental health residential treatment to try to learn better coping and problem solving skills and healthy strategies when dealing with negative emotions, so as not to internalize them resulting in depression with suicidal plans. Other goals included learning how to better deal with frustrations, verbalize feelings, increase awareness of family dynamics, identify maladaptive control patterns, and increase her sense of capability and responsibility.

The insurer did not act reasonably, or with sound medical judgment, or in the best interests of the patient.
	
Based on the above, the medical necessity for the mental health residential treatment services is substantiated.  The insurer's denial is reversed.