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

Nature of Statutory Criteria/Case Summary: An enrollee has requested residential behavioral health treatment services for treatment of his behavioral health condition. The physician reviewer found that modern psychiatric practice is aimed at treating individuals in the least restrictive setting to consolidate treatment gains and foster autonomy, harmonize relationships and mental wellness. Due to the multiple factors and unique considerations, determination of the appropriate level of care for adolescents with autism, addiction, depression and learning disorder, in context of defiant behaviors and family dysregulation, represents a challenging endeavor. Clinical guidelines and patient placement criteria from professional organizations have been developed to assist with the determination process, and it is the task of physicians and therapists working directly with the patient population to interpret and apply these tools.  In this case, the patient was struggling with the developmental stage of identity formation.  The confluence of contemporaneous psychiatric, characterological, addictive and biological components fueled a formidable symptom complex that placed the patient at risk for a poor outcome in the absence of specialized care in a 24-hour setting.  Additionally, the patient failed less restrictive alternative interventions and had a suboptimal family environment characterized by porous boundaries. Further, a supervised setting was recommended following a comprehensive psychological evaluation. As such, initial placement at the residential level of care represented a safe, appropriate disposition that was reasonably expected to improve his condition and prevent a more serious episode of illness. However, there was a lack of medical records from the residential facility describing behaviors, symptomatologies, interventions or medication management. There were no psychiatric notes. Additionally, the aforementioned psychological assessment did not stipulate a time frame for the residential services while an alternative setting was also suggested. The patient presented to the residential facility because it was the next step after wilderness. At the time, he had been sober for an extended time, his relationship with his mother had improved and there was no mention of acute distress. Further, prior to the wilderness program, the patient had not required acute inpatient psychiatric care or failed intermediary settings, such as intensive outpatient programming, partial hospitalization or residential treatment. Under such circumstances, an initial course of residential care would be consistent with community practice standards, which would have provided the patient and his family a sognificant therapeutic opportunity to consolidate treatment gains, reorganize relevant family systems, develop healthy rituals, and establish both effective communication and meaningful boundaries. Thus, based on the documentation provided, the services at issue were medically necessary for treatment of the patients medical condition for a specific amount of time.  Final Result: The reviewer determined that a portion of the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.  Credentials/Qualifications: The reviewer is board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.