Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 


The parent of a 14-year-old female enrollee has requested reimbursement and prospective authorization and coverage for residential treatment center services provided from 2/5/15 forward. The Health Insurer has denied this request indicating that the services at issue were not and are not medically necessary for treatment of the enrollees separation anxiety disorder, generalized anxiety disorder, panic disorder, unspecified depressive disorder, and attention-deficit hyperactivity disorder (ADHD).  The physician reviewer found that Modern psychiatric practice aims to place patients in the least restrictive treatment setting. In general, community settings optimize treatment gains. However, transient placement in more restrictive settings is often clinically appropriate. It is the task of physicians and therapists working directly with the patient population to determine the appropriate level of care and length of stay. Clinical guidelines and patient placement criteria developed by professional organizations, such as the American Academy of Child and Adolescent Psychiatry (AACAP), help guide clinicians with this challenging task. 
 
In reviewing the clinical documentation, this patients illness burden continued to flourish despite intensive outpatient services. She did not have a nurturing peer group or supportive social network. She had family conflict. She was engaging in parasuicidal behavior with suicidal ideation, depression and anxiety. Thus, admission to the residential facility was safe, appropriate and consistent with good medical practice in the United States. The services provided were for active treatment delivered in accordance with an individualized treatment plan aimed at successfully transitioning the patient to a less restrictive setting. Considering her symptom complex and past treatment failures, the services and setting were reasonably expected to improve her condition and prevent a more serious episode of illness. However, the medical record does not justify the medical necessity of the residential setting after 6/24/15. By that date, the patient had completed more than three months of treatment which represents a placement duration consistent with community practice. Upon admission, the patient adjusted well to the program and completed a comprehensive psychological assessment in February 2015. On 4/2/15, her antidepressant medication was discontinued. On 5/6/15, the patient was focusing on herself and doing well in the milieu. On 6/2/15, family therapy focused on boundaries and goals, and discussed the upcoming school year. On 6/4/15, the provider noted the patients insight despite being upset. On 6/18/15, the patient had a reassuring and unremarkable routine psychiatric visit. On 6/24/15, the weekly note inferred a successful home pass. There were no nursing issues. Therapeutically, she had improved insight and decreased anxiety. 

In sum, applying the current practice guidelines and relevant peer reviewed literature to this particular case, residential treatment services from 2/5/15 through 6/24/15 were medically necessary for treatment of the patients medical condition. However, services from 6/25/15 onward were not and are not medically necessary based on the documentation provided. 

Based on the foregoing discussion, I have concluded that a portion of the services at issue were medically necessary for treatment of the patients medical condition. The Health Insurers denial should be partially overturned.