Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 14-year-old male with previously diagnosed bipolar disorder, type I, rapid-cycling type, admitted to residential treatment in December 2004 due to perceived escalating problems predominately directed towards his father and sisters. This included a pattern of tantrums at nighttime for up to two weeks followed by normal mood for several days. He also noted depressive episodes, including depressed and irritable mood, loss of interest, disrupted sleep, fatigue, and some suicidal ideations, short of any set plan for such. The patient cited his rage episodes as having begun at four years of age, becoming worse over the last three years, initially limited to home, but having begun to appear at school. This had led to 12 suspensions in the past year along with becoming more isolated from prior friends, parents noting him as tending to `wear friends out.` He also noted the tantrums to occur with racing thoughts, restlessness, and hyperactivity as well as becoming loud, agitated, and annoying to others. Finally, the patient was noted to be sexually provocative, attempting to fondle his sisters or expose himself to his father. Past outpatient treatment had included a variety of medications including SSRI antidepressants, which appeared to have worsened his course, as well as various mood stabilizers. These included Depakote, Lamictal, Trileptal, and possibly Neurontin. The patient appeared to have the greatest benefit from Lamictal. Lamictal was stopped due to development of an elevated CPK, thought necessarily due to the medication. As of the point of admission to residential treatment, the patient was receiving Trileptal and Zonegram. The patients admission mental status exam revealed him to be neat and clean in grooming, cooperative, and somewhat restless. His affective reactions appeared to be somewhat flat, depressed, and anxious. Speech was organized with relevant topics and coherent. He was also able to recognize some of his problems, but was unable to verbalize an understanding of what to do about those problems. Within residential treatment the patient was treated with a number of psychotherapies and continued to receive Trileptal. No other mood stabilizer was added but Wellbutrin, an antidepressant, was initiated. Through what appears to mostly have been limit-setting in addition to therapy per se, the patients impulsivity and mood vacillation improved significantly. Most of the nursing notes that document untoward behavior cite the patient as impulsive though without description of just how so other than for some cursing. All of the therapy notes cite the patient as actively participating.At issue is whether residential treatment services were medically necessary as of January 2005.All told, the patient did certainly appear to need a more structured setting than what he might have received at home, hence initial consideration of residential treatment was reasonable. However, the submitted records indicate the patient was ultimately discharged without a diagnosis of bipolar disorder but rather one of mood disorder not otherwise specified. It appears a portion of his difficulties stemmed from an oppositional defiant disorder, evidently with `family dynamic issues` at least somewhat etiologic. This would likely explain the improvement in his behavior and moods away from the home setting.  Furthermore, additional mood stabilizers were not added to the patients regimen during his admission. If the patient had been suffering from a rapid-cycling form of bipolar disorder, type I, it is not likely he would have been maintained on the same mood stabilizer he had previously received and been started on an anti-depressant. This would prove to be enormously destabilizing. In this instance, Trileptal was not adjusted at any point and Wellbutrin was added, without newfound difficulties. Therefore, I have determined the services at issue were not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.