Appeal type: Medical necessity
Decision: Overturned

This is a patient who was referred for residential mental health treatment to address behavioral disturbances in the context of mood and and co-occurring substance use disorder associated with impaired functioning and problematic behavior. The patient was diagnosed with moderately severe and unspecified depressive disorder; and, moderately severe cannabis use disorder. He has longstanding 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 continued symptoms of depression together with a history of social withdrawal, school failure/refusal, and mood instability associated with substance use with cannabis. He was referred to the residential treatment in an outdoor/wilderness setting in order to address the core symptoms of depression and relationship problems including parent-child relational problems and his lack of motivation and the moderately severe substance use disorder with cannabis.
The patient has a history of outpatient treatments without sustained benefit. There has not been a suicide attempt, or violent and aggressive behavior related to anger and impulse control problems. However, the patient has conflict with his parents that did include lack of motivation and problematic behavioral disruptions that included abuse of tobacco, alcohol and cannabis, and bouts of running away.
Initial evaluation upon admission for residential care revealed a mental status examination that was free of severe psychiatric symptoms such as psychosis, thought disorder, severe cognitive impairment or active suicidal ideation. Mood was dysphoric and affect was anxious together with a history of problematic behaviors that included academic failure due to truancy and conflict with parents, and other behaviors that were self-destructive or reflective of severe mood disturbance including social withdrawal and self-treatment with cannabis. The patient's anxiety included social anxiety associated with problematic interpersonal functioning at school and at home. He was described as depressed with anxious demeanor, but cooperative and calm during the assessment. Insight was limited and judgment impaired with poor control of impulses. The patient had no acute general medical conditions or abuse of other substances of abuse.
The health plan's determination is overturned.
The patient was noted to gain insight and showed improve control of impulses. He remained dysphoric with anxiety that included social anxiety, apprehension, nervousness, tension, sleep disruptions, irritability and excessive worry. Family-focused sessions were provided with steady improvement that was modest. The patient was treatment plan compliant and had started to work earnestly with regard to cognitive behavioral therapy (CBT) and other evidence-base therapies while participating in milieu and activity therapies designed to build self-confidence and life skills.
The patient was noted to increasingly be more at ease with peers and staff, and better engaged with group and individual sessions including the beginning incorporation of cognitive behavioral therapy (CBT) skills. He worked on educational assignments and had frequent family focused sessions to address issues within the family constellation. He consistently denied suicidal ideation or urges to be aggressive or act in angry impulses. He achieved mood regulation and became better motivated to participate in treatment including involvement in recovery groups and other therapeutic interventions to support abstinence from cannabis and other substances of abuse. The patient was subsequently referred for clinically appropriate aftercare at the time of discharge. The correspondence and case summary indicate that the patient steadily participated in mental health services with better functioning and improved mood. He was at risk for regression upon return home prompting the recommendations for continued mental health and family focused treatment. Again, the treatment team recommendations for clinically appropriate aftercare were to have continued involvement with intensive and structured therapy, as well as psychiatric aftercare.
The patient's admission and continued residential level treatment through discharge is reasonable and in the best interest of the patient; he presented with and continued to display clinical features and symptoms that necessitated the admission and the continued residential level services as he struggled to engage in treatment and had intermittent bouts of affective instability that did require residential level structure and monitoring with active treatment. He had a history of treatment failure with lower level services and had recently displayed significant problematic behaviors with maladaptive coping, emotional regulation problems, distress problems, interpersonal functioning problems and day-to-day functioning problems that included academic failure in the context of severe mood and disruptive and substance use disorders. He continued to represent a safety risk and relapse risk and could not have been effectively managed in a less restrictive treatment environment through discharge.
Moreover, the monitoring, structure and intensity of residential services were medically necessary in keeping with prevailing standards of medical practice.