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

The patient is a 19-year-old female with a history of long-standing use of marijuana. She was dismissed from college due to recurrent use of the substance as well as poor academic performance. The patient had been using marijuana 3-4 times per week with last use a week prior to entrance to residential treatment. She was eventually arrested on possession charges and informed in court that charges would be dismissed if she completed a residential treatment program. The patient also previously used Xanax to lessen her anxiety with last use a month prior to entering residential treatment. After entering residential treatment the patient was diagnosed with cannabis dependence, alcohol abuse, anxiety disorder  not otherwise specified, attention deficit disorder, depressive disorder  not otherwise specified, and borderline traits. She attributed her anxiety to a lifelong course of such, though worsening in 2002 after her horse was injured. Following the injury of her horse, the patient started self-mutilating and ultimately attempted suicide by overdose. She was neither actively self-mutilating nor suicidal at the time of her admission to residential care. Her admission exam, formulated by the consulting psychiatrist, noted her to have a `full range` affect and her mood as `mildly anxious,` otherwise entirely linear and devoid of either psychosis or suicidality. The patient was also noted in most nursing notes to demonstrate `good eye contact` and bright affect, though with depressive ratings frequently in the realm of 7/10. She was also noted to be anxious but overly reliant on Xanax, freely noting herself as `too selfish` to support anyone and I don't want to talk to anyone about my anxiety, either. I want my Xanax. However, because of concurrent concern that the patient suffered from ADHD, she was also begun on a course of Adderall XR as well as Effexor XR, though she didn't find the latter useful in lessening her anxiety. The Effexor was changed to Paxil CR. Xanax was also initially begun and was later changed to Klonopin. The Paxil was ultimately thought to have resulted in much improved stabilization of the patients anxiety disorder to the extent that she was able to stop any supplemental Xanax doses. The patient was also able to participate in non-pharmacological ways to reduce stress including yoga and chi kung. At issue is whether the residential treatment services the patient received from January 2005 through February 2005 were medically necessary for treatment of the patients medical condition.Though the patient did certainly suffer from some anxiety-spectrum disorder as well as cannabis dependence, it is striking that she was easily able to stop using it a week prior simply with the legal mandate that she enter treatment, lest her charges of possession not be dropped. Additionally, while in residential treatment the patient did not appear to demonstrate a particularly compelling degree of either anxiety or depression based upon the documentation provided. That her medication course was fairly benign would support the notion of her anxiety not being that paramount. As such, it appears that treatment could have taken place on an intensive outpatient or partial hospitalization basis. Therefore, I have determined that the services at issue were not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.