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

The patient is an 18-year-old female admitted to residential treatment in March 2006 with an increased level of depression and escalating substance abuse. The record indicates she begun to use alcohol at the age of 12 and progressed to daily use between the ages 14 to 16.  The patient later used cannabis and began using amphetamine at age 13, initially snorting, then smoking, and finally mixing it with heroin and injecting it in the year prior to admission. She reported daily use of significant quantities of amphetamine and heroine. The patient described herself as always depressed and noted seasonal variation in her mood, typically more depressed in the winter months. Her symptoms included irritability, disrupted sleep patterns, low energy, and low self-esteem. The patient often expressed hopelessness and suicidal ideation and claimed to have made several suicide attempts previously. Periods of high energy, increased creativity, and persistent insomnia were also observed. At the time of admission, the patient was taking Wellbutrin XL 300mg, Prozac 20mg, Trazodone 150mg, and Seroquel 200mg. There was a longstanding history of high risk behaviors and truancy in order to facilitate her use of drugs and a troubled relationship with her parents. A family history positive for mood disorder and substance abuse was also noted.  The initial mental status exam revealed dysphoric mood and occasional tearfulness. The patient was diagnosed with mood disorder, polysubstance dependence, disruptive behavior disorder, and rule-out bipolar disorder and borderline traits.  During the course of her treatment, there were a variety of therapies and medication changes included the discontinuation of Prozac and the initiation of Lamictal. In April 2006, the treating psychiatrist noted continued mood swings and urges to use drugs. In May 2006 her mental health provider cited the patients low frustration tolerance and impaired sleep and in May 2006 again noted mood lability.  Lamictal was begun due to the probable diagnosis of bipolar disorder and the need for a mood stabilizing medication. As of April 2006 the patient was described as having no sense of herself without  drugs and a persistent attachment to the druggie lifestyle. The patient frequently denied the need for treatment and vowed not to continue with treatment once she turned 18. A change in perspective was noted in May 2006 and she had a positive home visit with her parents when she was released briefly on pass. Continued emotional instability was noted in May 2006 and her provider expressed a concern that the patient did not see the payoff in being sober, placing her at high risk for relapse. in June 2006 the patient acknowledged her struggle with regard to giving up some of the people and things that I need to in order to better my life and the lives of my family and people I care about.  In June 2006 she resolved not to hang out with old friends, and could more clearly define her fears about going home. In July 2006 the patient and her parents formulated a home behavioral contract and the tone of the interactions was positive with the patient commenting It was easy to fill in the behavior contract. The patient was discharged from residential treatment in July 2006 with diagnoses of bipolar disorder, type II, polysubstance dependence, parent-child relational problem, disruptive behavior disorder and borderline personality traits.  The patients parent has requested reimbursement for residential treatment services provided from April 2006 through June 2006. The Health Plan denied the request based upon a determination that these services were not medically necessary.The patients behavior clearly evidenced profound self-destructiveness. She frequently glorified her drug use and her behavior was hostile with externalization of her conflicts. It was not until early May that she had shifted in this perspective. Her mood symptoms persisted and her medications were adjusted accordingly. By the end of May, the mood lability lessened and there was a slight improvement in depressive symptoms. The patient continued to show improvement over the next month such that she was able to be discharged home in early July. By that time she had gained insight into the dangers of her continued drug use. All told, the evidence indicates the patient made slow but persistent progress which is a very positive outcome given her history. Therefore, I have determined the services at issue were medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.