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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for individual therapy, electroconvulsive therapy (ECT), residential treatment at a facility that specializes in treating multiple mental health and substance abuse diagnoses for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that there is support for a portion of the requested services in this clinical setting. This is a patient who shows an enduring pattern of an inability to maintain sobriety.  He has a pattern of dangerous behaviors of overdosing on prescription medications, and has been persistently impulsive in gambling and purchasing medications over the internet. He now uses kratom. He has been noncompliant with treatment plans and medication regimens. He has shown inappropriate behavior towards others, has been assaultive against his parent, has shown verbal aggression against staff in programs, and was intrusiveness towards peers in programs. The record shows that he has had at least 12 hospitalizations over the last year, giving strong evidence of this patients uncontrolled behavioral condition. He has been in and out of multiple ambulatory levels of care, all of which were unsuccessful.  He lacks insight and coping skills, as well as accountability. This patient requires a structured, contained environment in which he will receive an interdisciplinary approach to his treatment with more rigorous and regular reassessment by his physician and therapists. This patient requires multiple hour per day treatment through multiple groups per day. It is in this type of setting where he has a chance of developing some insight into his behavior, become aware of his relapse triggers, learn and practice coping skills, and begin to develop an ability to contain his impulsivity. For these reasons, residential housing at a facility that specializes in treating multiple mental health and substance abuse diagnoses is medically necessary for the treatment of this patient. However, ECT is not medically necessary, at this time. ECT would be appropriate if he failed the usual treatments for depression during a three month period of being clean and sober. With regard to individual psychotherapy, this service is not medically necessary, at this time. The patient must develop a degree motivation and desire to remain sober, as well as commit to maintaining compliance with a medication treatment regimen. When substance use is ongoing it is difficult to assess the patients true psychiatric condition and medicate appropriately. Specifically, residential treatment at a facility that specializes in treating multiple mental health and substance abuse diagnoses is medically necessary but ECT and individual psychotherapy are not medically necessary for treatment of this patient, at this time. Final Result: The reviewer determined that a portion of the services is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: The reviewer is board certified in 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.