Appeal type: Medical necessity
Decision: Overturned

Mental Health
Mental Health: Residential

The patient is a female diagnosed with moderately severe and recurrent major depressive disorder, persistent depressive disorder, unspecified anxiety disorder, unspecified eating and feeding disorder, psychological factors affecting physical condition (ulcer with bleeding), obsessive compulsive personality, and elements of unspecified and other posttraumatic stress disorder (PTSD) including complicated bereavement. The patient presented with worsening symptoms of her anxiety and depression in the context of the eating disorder and grief associated with the recent death of her father.

The patient was referred for residential treatment by her community clinicians due to her decline in functioning and worsening symptoms of the co-morbid psychiatric disorders, as well as over-use of her Ambien and over the counter medications used to numb self. Again, at the time of admission to residential level services, the patient had experienced worsening symptoms precipitated by multiple stressors with functional impairment and somatic symptoms of anxiety and depression.

The patient attended residential services with the structure, intensity of services and monitoring consistent with residential programming with occupation-specific programming including intensive therapy and nutritional supports with a meal plan. Specifically, she received individual, group, activity-based, wellness and other therapeutic interventions. During the course of treatment, she was noted to make slow and steady progress with ongoing sessions together with individual, group and other evidence-based psychosocial therapeutic interventions that included cognitive behavioral techniques and mindfulness/yoga and involvement in transference-based treatment. She remained on her psychotropic regimen of Lamictal and Lexapro with supplemental zaleplon, Abilify and gabapentin to address residual symptoms of depression, insomnia and anxiety.

In summary, progress notes during the timeframes under review from indicate that the patient was gaining independence but struggling with residual symptoms of anxiety and depressive ruminations associated with grief, and, bouts of intense anxiety with regard to her past trauma and the bereavement. In this regard, the patient exhibited high body distress with high levels of anxiety with regard to any consideration of transition to lower level services. She remained medically stable, and she did not pose safety concerns which were monitored. She remained on her medications targeting anxiety, depression, and trauma-related symptoms. Again, there were no general medical complications and she tolerated her medications without adverse effects with adherence. The patient was noted to be ready for discharge with a discharge date pending. Plans were in place for an appropriate step down with supports. She remained in residential care with continued supervision and structure and intensive mental health services in order to continue working on her coping skills and her trauma and grief related problems. The subject under review is the medical necessity for continued residential mental health treatment.

The health plan's determination is overturned, in part.

For a certain portion of the time frame the requested service of residential mental health treatment is medically necessary for this patient.  The documented records reflect the intensity of services, structure and monitoring consistent with residential level treatment and standards of care. Moreover, the services provided are in keeping with prevailing standards of medical practice for the conditions under treatment in this case with evidence-based treatments; and, the requested services/treatment being provided in this case were clinically appropriate, and are backed by credible scientific evidence known to benefit patients with the conditions diagnosed in this case. The duration of services were clinically appropriate and medically necessary and provided with well-established treatments known to benefit patients with the comorbid conditions diagnosed in this case and noted in the clinical summary. The patient could not have been effectively treated with lower level services or in a less restrictive treatment setting prior to a specific date, at which time the patient was capable of a step down to lower level services and treatment. This answer is consistent with the scientific literature and guidelines referenced below.