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

The patient is a 16-year-old female with a history of atypical bipolar disorder, oppositional defiant disorder, polysubstance abuse, and borderline personality traits. She was admitted to inpatient treatment on 11/30/03. The patient was noted as given to burning and lightly cutting on herself, with episodes of running away from home, skipping school, performing poorly at school and using drugs. The patient cited herself as excessively sensitive, needing attention, and given to worry. She was also troubled by sleep continuity disturbance and a tendency towards nightmares, which would lead her to then lay down with her mother. The patient had a minor physical altercation with her mother after her mother refused to let her go to the movies. This led to an inpatient admission on a 5150. This was one of very many arguments between the patient and her mother. It appears most of the patients substance use had involved marijuana, though the patient had been abstinent for about ten days prior to admission. Admission mental status exam noted the patient to be hostile and dysphoric. It was also noted the patient had not taken any of the previously prescribed Lexapro, Depakote or Abilify.The patient was not actively suicidal and she began taking medication in the form of Abilify 5 mg on 12/5/03. Thereafter, the patient was referred to adolescent partial hospitalization/day treatment program. After being discharged on 12/8/03 to begin the day treatment program on 12/9/03, the patient left her mothers home and went to stay with her stepfather, which appears to have also been an unstable environment. After the patient was brought to the day program by her stepfather, her mother came to the hospital and there was yet another altercation. This resulted in the patient being deemed a danger to return home, and she was thereby readmitted. Again, the patient was noted to be hostile, dysphoric and showed poor insight upon admission. She was not actively suicidal. On 12/14/03, the patients psychiatrist noted her to be tolerating Abilify adequately with no side-effects noted. Her mood was generally subdued. On 12/15/03, the patient noted she was feeling really, really well. Her medication, Abilify, was maintained at 5 mg per day during this inpatient stay from 12/10/03 through 12/17/03. On 12/15/03, she was noted as depressed because her boyfriend broke up with her on the telephone but stated she had no suicidal ideation.A request has been made for reimbursement for the treatment services the patient received from 12/4/03 through 12/8/03 and from 12/10/03 through 12/17/03. The Health Plan has denied this request indicating the services at issue were not medically necessary.The submitted clinical information does not substantiate the need for inpatient treatment as of 12/4/03. Per a psychiatrist note of 12/2/03, the patient was initially not even thought of as in need of medication at all. Though she was ultimately started on Abilify, this could just as well have taken place on an outpatient basis through the day treatment program by 12/4/03. As for the second admission, given that the patient was already at the day treatment program, it would have been medically reasonable and appropriate to continue with day treatment. While the patient may not have been able to continue living with her mother, the submitted evidence does not demonstrate the inpatient treatment services were medically warranted. All told, the patient could have received appropriate treatment in a partial hospitalization/day treatment program. Accordingly, I have determined the services at issue at issue were not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.