Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Depression And Substance Abuse.
Treatment: Continued Residential Mental Health Treatment.
The insurer denied the Continued Residential Mental Health Treatment.
The denial is upheld. 

The patient is an adolescent male. He was referred for residential mental health treatment in order to address behavioral disturbances in the context of a history of attention deficit hyperactivity disorder (ADHD)-inattentive type, parent-child relational problems, and co-occurring cannabis and alcohol and tobacco/nicotine use disorders associated with impaired functioning and problematic behaviors at school and home.

The patient presented with longstanding and worsening issues with self-esteem, confidence, and relationship problems together with stressors within the primary support, educational and social environment domains; the patient has been in past treatment settings with lower-level treatment with continued behavioral disturbance and high-risk behaviors that included stealing from his parents, lying, defiance of authority figures and bouts of anger.

The patient was referred to the residential treatment following Wilderness Treatment. The referral and admission to residential treatment was recommended in order to address the core symptoms of the co-morbid psychiatric disorders of ADHD (attention deficit hyperactivity disorder) and mood disorder and co-occurring substance use disorders, and to address relationship problems including parent-child relational problems and his lack of boundary control and problematic behaviors that had persisted despite the best effort of his parents and community providers.

The patient was referred and admitted to the Residential Treatment. The patient underwent comprehensive evaluation with treatment planning that included therapeutic interventions to improve coping skills and self-esteem, as well as individual and group and family therapy to address the co-morbid disorders, and programming that would target his substance use disorder. The treatment plan included the goals of improved coping; breaking the cycle of self-destructive behaviors including anger issues and impulsive aggression; and the development of healthy relationships and functioning.

The program focused on organizational skills; self-care; peer relationships; and other life skills as well as behavioral and emotional regulation with milieu, individual, group, family, and other interventions aimed at improving life skills. The patient struggled with treatment and was dismissive at first, but gradually participated actively in the treatment plan and worked on therapeutic, social, and emotional functions in the context of a therapeutic milieu with a residential level of structure consistent with a behavioral health program and setting that included ongoing medication management with a psychiatrist.

No, the Continued Residential Mental Health Treatment was not medically necessary for this patient.

The patient was noted to be engaged in treatment and capable of working with the clinical providers and family to address the remaining issues to include relationship and interpersonal functioning with authority figures, peers, and family, as well as continued treatment with Medication Management and other clinically appropriate therapeutic interventions to address the co-occurring psychiatric and substance use disorders. Therefore, the residual symptoms of the psychiatric disorders; and problems with psychosocial, educational and daily functioning were amenable to treatment in a less restrictive environment with lower level services and the monitoring, structure and intensity of residential services were no longer medically necessary, as indicated by the patient's progress and engagement in the ongoing treatment of his co-occurring disorders.

In summary, the patient's treatment could have been reasonably and effectively provided with lower level services in a less restrictive treatment environment. The patient's psychosocial stressors were not so severe to prevent ongoing assessment and treatment at a lower level of care in this case scenario. Moreover, there are no general medical issues, no co-occurring substance use disorder treatment issues, and no other clinical features that would have warranted continued residential level treatment or 24-hour monitoring in this case scenario.

This answer is consistent with prevailing standards of care and with NY State instruction for this review including the application of NY (New York) State LOCADTR (level of care for alcohol and drug treatment referral) Criteria and ASAM (American Society of Addiction Medicine) Criteria, referenced below, as well as the scientific literature, referenced below.