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

An enrollee who was admitted to the inpatient facility, with auditory hallucinations. He denied any suicidal ideation, self-harm, or substance use. Review of his medical records noted that the patient had slept well. His thought process was tangential and he denied any suicidal or homicidal ideation. His medications were not changed on this date, and his valproic acid level was therapeutic. The patient displayed some grandiose thoughts, and was euthymic. He reported some continued auditory hallucinations that were not bothersome, and he denied suicidal and homicidal ideation. He was started on lithium on this date. The patient substantially participated in individual therapy, and showed progress and cooperative behavior in all group activities. The patient did not demonstrate understanding of the reasons for his hospitalization. The patient presented with grandiose thoughts. His hair was noted to be disheveled. His thought process was goal oriented and he perseverated on his discharge. His memory was noted to be intact. He was not exhibiting aggressive behavior. The patient was less grandiose and was not exhibiting any self-harm behaviors. His mood was dysthymic and he was noted to be cooperative. He denied any suicidal or homicidal ideation. The progress notes indicated that the patient denied hallucinations, reported a good mood, and did not express any suicidal or homicidal ideation. Medications during the hospital stay included lithium, Depakote, Zyprexa, and Lamictal. He participated in group therapy, and individual therapy sessions. The patients diagnoses include bipolar affective disorder with psychotic features, autism spectrum disorder, and generalized anxiety disorder. The records document the patient was admitted to the inpatient unit due to an episode of apparent mania with auditory hallucination. The patients hallucinations were not command in nature nor did they appear disturbing to the patient. The patient initially showed minimal insight into his need for therapy, but as his treatment progressed, his insight improved. He was noted to be cooperative throughout his inpatient admission. He was interacting with peers and staff appropriately and was not displaying any aggression. He was not reporting any medication side effects and did not express any suicidal or homicidal ideation. His parents were involved in treatment. He did not have a history of substance use or significant medical problems. It appears that the initial portion of his stay was medically necessary due to his psychosis and mania. However, after several days in the hospital, he improved significantly and it appears he could have transitioned to a less restrictive setting.  The patients presentation had a composite score of on the Adolescent Level of Care Utilization System (CALOCUS). This score is judged by the acuity of the patients symptoms and environment during the period, by which time the patients symptoms had substantially resolved. A score of correlates with a treatment intensity level of three, which is consistent with intensive outpatient services. The patient presented with some risk of harm, due to a lack of any active suicidal ideation or self-harm behaviors in the context of a history of manic symptoms which elevate his risk of harm. His functional status was moderate, as he had issues with role performance due to psychiatric symptoms. His medical, addictive or psychiatric co-morbidity was none due to his overall medical stability and lack of substance use. The level of stress in the patients recovery environment was mild, as the patient had a stable living environment to which he wanted to return. He had a supportive recovery environment as the patients family was supportive of his treatment needs and were engaged in his treatment. His resiliency and treatment history was equivocal, as he had a good treatment response overall, as his symptoms decreased while in the inpatient hospitalization; but there was some history of outpatient treatment noncompliance and failure. His acceptance and engagement was constructive, as he participated in therapy. Parent acceptance and engagement was constructive, as his parents worked actively and constructively with providers. According to the CALOCUS, the inpatient care criteria were not met. Thus, the inpatient psychiatric treatment services provided by The Menninger Clinic from were medically necessary for treatment of this patients behavioral health issues, but services from were not medically necessary.Final Result: The reviewer determined that the requested services were partially medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned for the dates through. The Health Plans denial should be upheld for the dates.Credentials/Qualifications: The reviewer is board certified in psychiatry with a subspecialty certification in child and adolescent psychiatry, and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.