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

The patient is a 17-year-old male with an approximate four-year history of predominantly marijuana use, but supplemental use of other drugs such as cocaine. He was admitted to residential treatment in March 2005 following a six-week wilderness program. This had followed having been enrolled in another residential treatment program for six months, though taken out prematurely. Thereafter, he relapsed in his use of drugs, hence his referral to the wilderness program. The patient was referred to the residential program due to his mothers concern that he might relapse yet again. The patient identified his drug use mostly as stemming from his upset over his parents divorce when he was 12, since which time he had used drugs to numb his various feelings. He also noted frequently feeling depressed. As of the time of his admission to the most recent residential program, he noted feeling depressed some of the time and finding it to be independent of external events. Approximately once a week he would feel very sad and begin crying for apparently no reason. He had also been arrested in January 2004 for possession of cocaine and was on probation until August 2005, using marijuana and cocaine on a daily basis by that point. His depression had been treated in the past with Depakote and Wellbutrin for approximately two weeks but his father took him off of the medications. The patient did not notice any improvement during that time. He was later treated with Lexapro for a month, once again not noticing any improvement. Upon admission to the most current residential program, he was diagnosed with mood disorder - not otherwise specified; parent/child relational problem; and cannabis dependence. He was treated with a variety of psychotherapies, without medications, and was not regularly evaluated by a psychiatrist. Over the course of treatment, the patient did not show any increase in mood, the notes indicating, his mood remained fairly flat. The patient was also noted as having some problems with pornography, though the extent of this is unclear. The submitted documentation indicates the patient was suddenly withdrawn from the residential treatment program by his father.At issue in this case is whether the residential treatment services at issue were medically necessary for treatment of the patients behavioral health problems.  The patient clearly has a problem with cannabis dependence and depression, the latter likely of major depression proportion. However, complicating matters is that of both parents pulling him from whatever sort of treatment he had begun without there having been any concerted effort at outpatient treatment. It also appears that the entire story of the family dysfunction is not entirely known. Clearly, family therapy is needed but has yet to occur, perhaps because of the parents division. Finally, it is hardly clear that the patient is not suffering from a significant depression or that pharmacology would not be of assistance. Of note is the discharge summary from residential treatment which points to the persistence of the patients depression. Two meager trials of medication, one of which lasted but two weeks, is not sufficient to conclude that medications would not be beneficial. As for the residential treatment itself, no psychiatrist notes were submitted and follow-up, such as it was, was conducted by a psychiatric nurse practitioner. The submitted records do not demonstrate the services at issue resulted in improvement in the patients condition or adequately addressed his needs. All told, the care of this patient could have been meaningfully approached on an outpatient basis prior to consideration of a more intensive level of care. Based upon the information set forth above, I have determined the services at issue were not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.