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

The patient is a 15-year-old female who was admitted to an inpatient psychiatric facility on 9/28/04 for treatment of continued running away from home, polysubstance use involving marijuana, amphetamine and cocaine use, promiscuous sex, stealing money, and continued defiance at home. The patients psychiatrist noted the patient had a long history of being very oppositional. She was also noted to refuse to take responsibility for her behavior and the patient cited feeling hopeless and worthless as secondary to being adopted. She was initially diagnosed as having a mood disorder  not otherwise specified and oppositional defiant disorder. She was seen in a variety of group therapies and had family therapy with her adopted mother and father via the telephone, but not in person. The patients admission medications included Zoloft and Synthroid; the former was ultimately switched to a combined regimen of Trileptal and Seroquel.Throughout her stay, the patient was noted as dramatic, brash, and self-centered, with a tendency to rationalize much of her behavior on the basis of being adopted. At other times, she claimed to be angry because of her fathers emotional distance. An extensive psychological evaluation in October 2004 noted the following: desire to display an image of daring and defiance, an impulsive and socially irritable manner, and her voiced pride in being assertive, brusque, impudent, cheeky, and outspoken. Actions that raise questions of personal integrity such as cruel indifference to the rights of others indicate a pervasively defiant social conscience. The Millon Adolescent Clinical Inventory suggested axis II traits of antisocial and aggressive/sadistic personality traits, and conduct disorder and polysubstance dependence were diagnosed on axis I. At one point, she noted hearing the voice of Satan, though the exact message within was never described as the patient was noted as seeming rather bright and pleasant, social with peers and staff, and excited for Halloween all in the same day. No further documentation of anything akin to psychosis is noted anywhere else in the submitted records.Both individual as well as group notes often point to the patient as appearing bright affectively, compliant with the treatment inclusive of school, and not at all suicidal. Though the staff indicated the patient sometimes voiced homicidal ideations, i.e., considering breaking someones nose or kicking them in the stomach, there is no indication that the patient had a history of such actions or that such actions were actually imminent. The patient was able to earn B level grades in school and tested as having a normal, full scale I.Q. of 98.A request has been made for continued psychiatric residential treatment services. The Health Plan indicates continued residential treatment was not medically necessary as of 12/8/04.All told, this patient appears to have both conduct disorder and polysubstance dependence, as well as underlying personality disorder that is notably narcissistic to frankly antisocial in origin. She may also suffer from an underlying bipolar disorder. However, to the extent that her overt conduct settled by 12/8/04, there are no grounds to support continued residential treatment as of 12/8/04. In light of the submitted documentation, a less intensive level of care was medically reasonable and appropriate as of 12/8/04. Therefore, I have determined that the requested services are not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.