Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Tetrahydrocannabinol (THC) and Marijuana abuse

Treatment: Inpatient residential treatment

The insurer is denied coverage for inpatient residential treatment.

The denial is upheld. 

This male patient has a history of nicotine abuse, marijuana abuse, and oppositional defiant disorder (ODD). He presented to the rehabilitation facility because of tetrahydrocannabinol (THC) and marijuana abuse. His parents noted that he had trouble making and keeping friends. He was also verbally violent towards his mother. The patient was admitted to receive residential treatment services. During the admission the patient participated in group and individual therapy sessions. A psychological assessment was performed. The patient was diagnosed with generalized anxiety disorder (GAD), unspecified depressive disorder, a nonverbal learning disorder, and attention deficit hyperactivity disorder (ADHD). He was on 150 milligrams (mg) of oral Wellbutrin a day. The patient was able to function well in the program. He did make some errors with judgement and decision making but was able to gain insight to improve decision making. The patient was discharged to another residential treatment facility for further care.

The American Academy of Child & Adolescent Psychiatry (AACAP) Practice Parameters for the Assessment and Treatment of Children, Adolescents, and Adults with Oppositional Defiant Behaviors reports that one can consider other out of home community based alternatives to residential treatment such as therapeutic foster care or respite care but there is no mention of wilderness programs. Wilderness programs are an adventure based therapy with use of wilderness for purpose of therapeutic interventions often using the survival approach which this facility used. The aim is to become more self-reliant and have more self-respect. This is not considered a standard treatment for children with oppositional defiant behaviors. Also, the American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Substance Use Disorders reports that residential treatment is indicated primarily for individuals who do not meet clinical criteria for hospitalization but whose lives and social interactions have come to focus exclusively on substance use and who currently lack sufficient motivation and/or substance-free social supports to remain abstinent in an ambulatory setting. For these individuals, residential facilities provide a safe and substance-free environment in which residents learn individual and group living skills for preventing relapse. The duration of residential treatment should be dictated by the length of time necessary for the patient to meet specific criteria that would predict his or her successful transition to a less structured, less restrictive treatment setting.  In this case it appeared that this patient required a sober therapeutic residential treatment setting to learn better coping skills, improve identification of relapse triggers, improve insight and relapse prevention skills, increase sober supports, improve decision making, have better impulse control, decrease behavioral and mood symptoms as he was at risk for dangerous behavior if not in a residential treatment setting as evidenced by selling cannabis and purchasing fake money to buy substances from drug dealers and he reportedly had threatening behavior. However, this wilderness program was not considered a clinically licensed residential treatment due to lack of nursing staff and lack of psychiatric assessments on site.  

The health plan did act reasonably with sound medical judgment, and in the best interest of the patient.

The carrier's denial of coverage for the inpatient residential treatment is upheld.  The medical necessity is not substantiated.