Appeal type: Medical necessity
Decision: Overturned

This is a patient referred by his community providers to a residential mental health treatment facility with admission in order to address severe symptoms of major depressive disorder and co-occurring substance use disorder with cannabis and alcohol. The admission to residential care was prompted by worsening symptoms of depression together with school avoidance/refusal and behavioral problems in the context of severe cannabis use disorder and trauma related symptoms. The patient is also diagnosed with severe major depressive disorder, generalized anxiety disorder including panic attacks and social anxiety, and cannabis use disorder.
The patient has had ongoing issues with persistent symptoms of depression and anxiety that had been treated since 2014 precipitated by an inappropriate sexual encounter when he was coerced into having sex with a male peer. He continued to engage in sexual contact that was viewed as problematic by the patient and his family due to religious and other cultural norms. Moreover, the patient developed trauma related symptoms and began coping with cannabis and alcohol use with avoidance of social contacts and school refusal. Despite ongoing treatment efforts, the patient had worsening symptoms of depression and anxiety with self-destructive and self-defeating behaviors that included social withdrawal, decline in academic functioning and escalating use of cannabis. The patient had also experienced family stress related to his substance use and increasing symptoms of depression resulting in a profound sense of hopelessness and low self-worth and other complications of the co-morbid psychiatric conditions despite receiving therapy and medication to address the mood and anxiety disturbances.
The patient was referred for and admitted to the residential program that offered comprehensive services including programming to include intensive family therapy and other therapeutic interventions to address the patient's co-occurring disorders.
Initial evaluation upon referral for residential care had revealed a mental status examination that was free of severe psychiatric symptoms such as psychosis, mood cycling or mania, formal thought disorder, severe cognitive impairment or homicidal ideation. The patient was described as having limited insight, impaired judgment and poor impulse control. Mood was dysphoric, and affect was anxious with generalized symptoms of anxiety and social anxiety with apprehension, tension, sleep disturbance, irritability, and excessive worry as well as trauma-related symptoms that included flashbacks, avoidance, numbing behavior, and nightmares. He was guarded and apathetic, indifferent, and demoralized with past and passive suicidal thoughts and deficient coping skills. He also exhibited attention and concentration problems and poor eye contact with slow speech and thought blocking.
The patient underwent comprehensive psychiatric evaluation with ongoing safety monitoring and treatment planning that included therapeutic interventions to improve coping skills including cognitive behavioral techniques (dialectical behavior therapy (DBT) and cognitive behavioral therapy (CBT) to address distress tolerance, mindfulness, emotional regulation and interpersonal relationships and functioning. The treatment plan included the goals of improved coping; breaking the cycle of self-destructive behaviors with regard to the substance use; and, the development of healthy relationships. Individual, group and family therapies were provided, and he had access to recovery groups including peer-supported and therapist led recovery groups. He had safety monitoring and structure to support abstinence from substances of abuse. He was maintained on his medication with adjustments as clinically appropriate and Focalin was added to a regimen of Abilify, Prozac and Lamictal.
The health plan's determination is overturned.

The patient's admission and continued residential level treatment is reasonable and in the best interest of the patient; he had and continues to display clinical features and symptoms that necessitated/necessitate the admission and the continued residential level services as he struggles to engage in treatment and has affective instability that does require residential level structure and monitoring with active treatment. He has a history of treatment failure with lower level services and had recently displayed significant problematic behaviors with maladaptive coping, emotional regulation problems, distress problems, interpersonal functioning problems and day-to-day functioning problems that included academic failure due to school refusal in the context of severe mood, anxiety and substance use disorders complicated by attention deficit hyperactivity disorder (ADHD) and trauma related symptoms. He continues to represent a safety risk and relapse risk, and could not have been effectively managed in a less restrictive treatment environment.
Moreover, the monitoring, structure and intensity of residential services were medically necessary in keeping with prevailing standards of medical practice, American Society of Addiction Medicine (ASAM) Criteria the application of NY State OASAS LOCADTR 3.0 Criteria and Guidelines.