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

The patient is a 17-year-old female has participated in a dual diagnosis partial hospital program due to polysubstance dependence, but continued to have problems with use of drugs, social issues, and poor recovery environment. The patients providers at the treatment facility have concluded the partial hospital program (PHP) is not sufficient for her treatment and recovery. The facility has recommended the patient be admitted to a 24-hour residential facility. The Health Plan reviewed the request and decided that PHP level of care was consistent with their guidelines and that residential level of care was not indicated.The current condition of the patient is that she continues to attempt to associate with older males who are drug users. She has comorbid psychiatric disorder, which has been diagnosed as bipolar disorder and is being treated with therapeutic levels of a mood stabilizer. The patient continues to demonstrate threatening behavior to her parents, is oppositional to rules and efforts to control her behavior, brought a knife to school and was expelled, and has mood swings that are consistent with a bipolar disorder condition. She has denial about her substance abuse and continued to use drugs during the period she was enrolled in the PHP.The patients past history is significant in that she was diagnosed with attention deficit disorder when she was 12 years old. She responded to stimulant medication, but started abusing drugs at approximately 13 years of age. She experimented with methamphetamine, alcohol, marijuana and other drugs. Prior to her admission to a dual diagnosis PHP, she was dating an older male who also a drug user and dealer. Her family is supportive but feels that they have no control over the patient due to her oppositional behavior, mood swings and denial about her drug problems. She also has a history of alcohol poisoning and ER intervention for such.A request has been made for authorization and coverage for residential treatment services. The Health Plan states that based on American Society of Addiction Medicine (ASAM) criteria the patient does not meet criteria for the residential level of care that has been recommended.The patients clinical history is consistent with the adolescent ASAM criteria for level III residential care. The patient continued to use methamphetamine, alcohol and drugs while in partial hospitalization and remains a moderate risk for withdrawal. Additionally, she has a dual diagnosis with the need to monitor her medication levels. Furthermore, she demonstrates 4 out of 5 emotional, behavioral or cognitive conditions and complications. Moreover, the patients readiness to change is poor and she requires high-intensity motivating strategies. She has severe relapse potential due to her bipolar condition/dual diagnosis. Finally, her current environment is dangerous to recovery. Given the documented failure of PHP as well as the patients continuing problems with impulsivity (as manifested by bringing a knife to school), peer relationships, denial of problems, and her bipolar disorder condition, a 24-hour medically monitored level of care is warranted. Therefore, I have determined the requested services are medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.