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

The patient is a 17-year-old male referred for residential treatment due to increasingly aggressive behavior at school.  Other behaviors included extensive use of marijuana and alcohol beginning at age 11, threatening to make bombs, threatening to shoot people, thievery, and sexual deviance. The latter consisted of bestiality, manipulation of peers to engage in sexual acts and sexual intimidation towards his sister. There is a 2001 report, which cites direct sexual abuse by his older brother on at least four to five occasions, as well as the observation of the brother forcing his sister to engage in sexual acts. By the time of his suspension from school in 2003 and formal placement on probation by the court, the patient was noted to have diagrams of bomb assembly culled from websites, had harassed and intimidated other students, showed up drunk and vomited in class, and continued to smoke marijuana. Outpatient treatment and a subsequent wilderness program did nothing to ameliorate the patients behavior, hence the referral to residential treatment.Review of the initial documentation shows the patient to have externalized. He was treated in a number of therapeutic contexts and evaluated longitudinally by a psychiatrist. Treatment of his substance abuse was complicated by parental use of cannabis. Celexa was tried and eventually tapered away. By way of the milieu and specific therapies he was felt to have improved sufficiently to allow for discharge from residential care on 4/4/04. The therapist however, continued to express concern for the satisfaction the patient derived from making inappropriate choices and his struggles with personal boundaries as they relate to his sexual disorder.Though this patient was diagnosed with depressive disorder NOS, sexual disorder NOS, and cannabis abuse, in addition to dependent and avoidant traits, he appears to have had a resounding conduct disorder, even by the most formal of DSM-IV criteria. It is not known why this was never formally diagnosed and given precedence as the most operative diagnosis. However, the approach to treatment, via residential placement, was indicated given the egregious nature of the patients behavior and the ineffectiveness of prior treatment modalities. The degree to which his conduct disorder can be attributed to the sexual perpetration by his older brother is questionable, but some of the references cited support a direct relationship. Complex family dynamics and inconsistent parenting, particularly concerning the use of marijuana, also contributed to the patients conduct disorder. Given the extent of his psychiatric illness, one would want to ensure sustained improvement in the target symptoms prior to egress from residential treatment. Considering the scope of the patients untoward behavior upon admission, it would be expected to take quite some time to yield improvement.  Affording the patient a sufficient length of time in residential treatment appears medically necessary. Based upon the information set forth above, I have determined the services at issue were medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.