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

The patient is a 17-year-old female admitted to residential treatment from May 2005 through October 2005 for treatment of very longstanding verbal aggression, oppositional defiance, depression, and self-abuse. She had been placed in several residential treatment facilities prior to the current one, but residential treatment was again recommended due to the persistence of explosive anger, severe defiance, disruptive behavior, severe deterioration of functioning in the family, depressive symptoms and irritable and labile moods. Preceding placement, she was receiving Trileptal 600mg/750mg, Adderall XR 25mg, and Prozac 20mg. The patients operative diagnoses were cognitive disorder, ADHD, oppositional defiant disorder, and mood disorder secondary to seizure disorder. While in residential treatment she had an EEG which was within normal limits and IQ testing which revealed an IQ of 77. Descriptions of her behavior and demeanor during the admission examination included uncooperative, agitated, labile, poor judgment, poor insight, irritable, uncooperative, complaining and impaired by cognitive delays but is able to participate in program.The patient was treated with a number of therapies including family visits. Her medications were maintained at the admission doses except for Trileptal, which was increased to 600mg/900mg.  Notes of relevance in terms of her symptoms and progress in treatment are as follows, in chronological sequence:The patient exhibited critical manifestations at a rate of 3 as compared with 0 during the previous reporting period, which is considered to be regression. The most serious behaviors observed include physically harms self at 2 and hits others at 1. Exhibited other behavioral manifestations at a rate of 889 as compared with 123 during the previous reporting period.She has been pleasant and cooperative during our sessions. She is beginning to take accountability for her actions.During the past reporting period exhibited behavioral manifestations at a rate of 456 as compared with 889 during the previous reporting period.Has had no incidents of cutting during this reporting period. Has progressed in the behavior enhancement program and is able to go off campus with her family for visits.Parents appear to be very supportive of treatment. Has had daily contact with them on the unit. The last few phone calls with her family have been more positive. Had an off campus pass during this reporting period. Parents reported the visit went well.During this reporting period, demonstrated 340 behavior manifestations compared to 427 last reporting period. Went on an off campus pass with her family in September 2005. Family reported this was a positive pass.Despite a number of prior residential placements, there is evidence that the patient was still impacted by her various diagnoses to such an extent that outpatient treatment was not yet an option. Her oppositional defiant disorder appears to have been the principle problem. Additionally, the patient tested in the borderline intellectual function range, not the mentally retarded range. Although there are cognitive limitations, there is clear documentation of her ability to glean something therapeutic from treatment resulting in a fairly successful residential treatment outcome. The patients behavioral deviation scores decreased notably throughout her stay and she was better able to tolerate interactions with her family as treatment progressed. It would appear that the patient derived more benefit from this treatment than from previous residential placements. Therefore, I have determined the services at issue were medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.