Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for inpatient mental health treatment and electroconvulsive therapy (ECT). The Health Plan has denied this request indicating that the services at issue were not and are not medically necessary for treatment of the enrollees behavioral health condition.  Findings:  The physician reviewer found that Based on the clinical documentation provided for review, the patient presented with a formidable illness burden. The patients mood disorder was characterized as severe with treatment refractoriness and complicated by alcohol use and anxiety. The patient had history of concerning suicidal behavior in which he wrote a suicide note and developed a plan for hanging. The patient had been depressed for nearly two years to the point where he neglected his activities of daily living and felt unable to leave home for fear of anxiety and panic attacks. The anxiousness was of particular relevance since it has been well-established in both clinical practice and the medical literature, such as the definitive Sequenced Treatment Alternatives to Relieve Depression (STAR*D) study, that anxiety-ridden mood disorders, without the complication of addictive illness, are notoriously difficult to treat and in general have poorer outcomes. ECT is recognized as a safe, rapid and highly effective neuromodular intervention available for the treatment of severe affective illness, including both unilateral depression and bipolar disorder. ECT is endorsed by the American Psychiatric Association as a first-line treatment for depressive episodes. The patient was having side effects from the ECT. After two treatments he was forgetful and still depressed. The psychiatrist added a second antidepressant, bupropion. The patient was lethargic, tired and obsessive per psychiatry, and, intermittently confused per nursing. The patient had mirtazapine reduced. The patient went for his fourth ECT treatment. Unlike the previous three treatments, this application was unilateral, rather than bilateral, in an effort to minimize the side effect while still providing a positive clinical response. Further, the patients gabapentin was discontinued due to balance problems. The nursing notes reflected the patients perception of some improved mood and decreased anxiety with the ECT, but ongoing dizziness and unsteady gait. The patient was displeased with the prospect of a premature discharge due to treatment access to ECT as he lived about two hours from the treatment facility. In sum, the patient was not stable for discharge as he was symptomatic and experiencing side effects while significant treatment variables were being manipulated. However, he remained engaged in active treatment during the hospital stay that was reasonably expected to improve his condition and prevent a more serious episode of illness. Further, due to the severity of the illness burden and barriers to appropriate aftercare, continued inpatient level of care until completion of the index course of ECT, optimization of the medication regimen and finalization of a practical discharge plan was safe and consistent with good medical practice. As such, based on the documentation provided, the inpatient mental health treatment and ECT provided were medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that a portion of the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: The reviewer is board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.