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

The patient is an 18-year-old female with previously diagnosed major depression, recurrent and oppositional defiant disorder. The patient was admitted to residential treatment on 8/25/03 due to persistence of depression accompanied by increasingly risk-taking and dangerous behaviors such as playing car tag, promiscuity, and periodic drug and alcohol use. Treatment involved a number of psychotherapies in addition to medication treatment. The patient was initially treated with Effexor and then with Lexapro, both of which were ineffective. She was thereafter treated with Wellbutrin, which resulted in a superior response.Chart notes of the patients psychiatrist state on 11/16/03 the patients mood still had not improved on Lexapro, even with a dosage increase two weeks prior. Staff saw her as withdrawn, but perhaps a little less irritable than she had been a month ago. It was further noted the patient engages in some entitled, controlling behaviors. At that time, she was receiving Lexapro 20mg per day. On 12/4/03, she was noted as more positive. According to the chart notes the patient was still blaming her parents but it was improving. Her mood was brighter and happier. By this time, the patient was receiving Wellbutrin SR 150mg twice daily. On 1/13/04, while still on Wellbutrin, she was noted as having done very well in the community. She went on a home pass at Christmas and did very well. Her mood was generally stable and still better overall on Wellbutrin. An individual therapy note of 1/22/04 indicates the patient was in a funny mood during this session. She wanted to not be serious but tried to make herself serious in order to make some progress. There is no documentation of risk-taking behaviors or even suggestions of such on the patients part by this date. The patient continued in residential treatment until 5/3/04.A request has been made for reimbursement for residential treatment services received from 1/1/04 through 5/3/04. The Health Plan has denied the request on the basis that the services at issue were not medically necessary for treatment of the patients medical condition.Based on the provided documentation, the patient appears to have stabilized by 1/13/04. This is well sustained by her therapists note of 1/22/04. While the patients clinicians voiced a concern of a propensity towards relapse were she to have left the program at a time they felt was premature, i.e., prior to 5/3/04, there is no indication that the patient was in any way so precariously balanced even by the early part of January. She also tolerated a home pass without untoward event. Based on the psychiatric chart notation about that time, specifically the note of 1/13/04, she appeared stable. This is the last formal psychiatric evaluation that has been provided. Thus, as of 1/13/04, the patients condition had improved to the point that continued residential treatment was no longer medically indicated. In light of the findings set forth above, I have determined that residential treatment services were medically necessary for treatment of the patients medical condition until 1/13/04. Thus, the Health Plans denial should be partially overturned.