Appeal type: Medical necessity
Decision: Overturned

Mental Health
Inpatient Mental Health

Diagnosis: Reactive Attachment Disorder
Treatment: Inpatient Mental Health Stay
The insurer denied the Inpatient Mental Health Stay.
The determination is overturned in part.

The patient has co-morbid diagnoses of reactive attachment disorder; autism spectrum disorder; posttraumatic stress disorder (PTSD); attention deficit hyperactivity disorder (ADHD), combined type; and, voyeuristic behavioral disorder associated with affective instability, impulsive aggression, and decline in social, family and other psychosocial functioning domains. The patient was brought to emergency services and admitted to acute inpatient level care for impulsive and aggressive behavior of a sexual nature with sexual assaultive behavior. The patient has a history of longstanding problems with impulse control with comorbid psychiatric conditions including the additional diagnosis of a reactive attachment disorder with subsequent development of enduring mood dysregulation, impulsive aggression and inappropriate sexual behavior, and decline in functioning in all relevant domains. 
The patient presented with limited insight and impaired judgment associated with the affective instability and constricted affect. He exhibited coping and personality traits/coping skills that reflected impaired judgment and poor control of impulses with the presenting features, as noted, and safety concerns. 
The patient has a trauma history and an attachment disorder reflecting early childhood trauma. The patient participated in milieu treatment modalities while his medications were monitored with psychiatric management. He was making progress and had remained engaged in treatments that included group, individual and family-focused sessions.
He was noted to be functioning better with a greater ability to manage his impulses but did not show improved insight; he was reluctant to discuss the reason for his admission, but indicated that he would do so with subsequent treatment in a residential program. 
The issue under review is the medical necessity of Inpatient Mental Health Services.
The services are medically necessary in part.
The patient's clinical history and presenting features did warrant the continued structure and monitoring of an inpatient setting with the intensity, scope, duration, and structure of inpatient level services in order to effectively address the patient's risk of relapse, continue to learn adequate coping skills to engage in an ongoing therapeutic process, and prevent treatment failure, while the treatment team and family worked toward a clinically appropriate disposition with continued mental health services to address the severe and persistent symptoms of the mental disorders diagnosed in this case. The patient has a history of failing to benefit from treatment in the community, and more recent risk for inappropriate sexual behavior and aggressive/violent behavior in the context of severe symptoms related to comorbid reactive attachment disorder (RAD) and ADHD and PTSD. His behavioral disturbances in the context of family and social impairments and severe symptoms associated with impulsive and aggressive behavior complicated the case as well as the potential for high risk behaviors that required continued intensive services. These factors support the assertion that the patient could not have been effectively treated at a lower level of care up until when the patient was fully prepared for a transition and immediate transfer to residential level care.
A reasonable residential program had been identified and the patient was deemed to be ready and fully prepared for discharge to residential care.