Appeal type: Medical necessity
Decision: Overturned

This is a patient referred for residential mental health treatment to address behavioral disturbances in the context of a mood disturbance and co-occurring substance use disorder associated with impaired functioning and problematic behavior. The patient was diagnosed with a moderately severe and unspecified depressive disorder; and moderately severe cannabis use disorder, as well as disruptive behavioral disorder. The patient has longstanding issues with self-esteem, confidence, and relationship problems together with stressors within the primary support, educational and social environment domains; the patient has been in past treatment settings with continued symptoms of depression together with a history of social withdrawal, and mood instability associated with substance use primarily with cannabis, but also use of tobacco and alcohol. The patient was referred to residential treatment in order to address the core symptoms of depression and relationship problems including parent-child relational problems and his lack of motivation and the moderately severe substance use disorder with cannabis. He presented with a history of violent behavior, and bouts of rage and impulsive aggression with threats toward others including his mother.
The patient has a history of outpatient treatments and other intensive treatment including attending a therapeutic preparatory school without sustained benefit. The patient has conflict with his parents including problematic behavioral disruptions and abuse of tobacco, alcohol and cannabis.
Initial evaluation upon admission for residential care revealed a mental status examination that was free of severe psychiatric symptoms such as psychosis, thought disorder, severe cognitive impairment or active suicidal ideation. His mood was dysphoric and affect was anxious together with a history of problematic behaviors that included academic failure due to truancy and conflict with parents, and other behaviors that were self-destructive or reflective of severe mood disturbance including social withdrawal and self treatment with cannabis. The patient's anxiety included social anxiety associated with problematic interpersonal functioning at school and at home. He was described as depressed with anxious demeanor, but cooperative and calm during the assessment. Insight was limited and judgment impaired with poor control of impulses.
The patient had no acute general medical conditions or abuse of other substances.
The patient is supported in his treatment effort by family. He is a student. There is no trauma history or legal issues in this case.
Diagnoses included the unspecified depressive disorder associated with oppositional behavior, unspecified disruptive disorder and cannabis use disorder, as well as parent-child relational problems, and, the problematic behaviors affecting educational and social and family functioning.
The patient was referred and admitted to the Residential Program. The patient underwent comprehensive evaluation with treatment planning that included therapeutic interventions to improve coping skills and self-esteem, as well as cognitive behavior therapy to address the mood disorder. The treatment plan included the goals of improved coping; breaking the cycle of self-destructive behaviors including anger issues and impulsive aggression; and, the development of healthy relationships and functioning.
The program focused on organizational skills; self-care; peer relationships; and other life skills as well as behavioral and emotional regulation with milieu, individual, group, family, and outdoor therapies/sport, as well as other interventions aimed at improving life skills. The patient actively participated in the treatment plan and worked on therapeutic, social, and emotional functions in the context of a therapeutic milieu with a residential level of structure and monitoring in a behavioral health program and setting that included educational services and ongoing medication management.
The patient was noted to gain insight and showed improve control of impulses. He remained dysphoric with anxiety that included social anxiety, apprehension, nervousness, tension, sleep disruptions, irritability and excessive worry. Family-focused sessions were provided with steady improvement going forward that was modest. The patient was treatment plan compliant and had started to work earnestly with regard to cognitive behavioral therapy (CBT) and other evidence-base therapies while participating in milieu and activity therapies designed to build self-confidence and life skills.
The patient was noted to be increasingly more at ease with peers and staff, and better engaged with group and individual sessions including the beginning incorporation of therapy skills. He worked on therapeutic assignments, and had frequent family focused sessions to address issues within the family constellation. He consistently denied suicidal ideation or urges to be aggressive or act in angry impulses. He achieved mood regulation and became better motivated to participate in treatment including involvement in recovery groups and other therapeutic interventions to support abstinence from cannabis and other substances of abuse. The patient was subsequently referred for clinically appropriate aftercare at the time of discharge. The correspondence and case summaries indicates that he steadily participated in mental health services with better functioning and improved mood. He was at risk for regression upon return home prompting the recommendations for continued mental health and family focused treatment. Again, the treatment team recommendations for clinically appropriate aftercare were to have continued involvement with intensive and structured therapy, as well as psychiatric aftercare.
The health plan's determination is overturned.
In this case, the patient could not have been effectively managed in a less restrictive environment for the dates of service under review. The residential structure, monitoring and intensity of services were warranted in this case scenario in view of the treatment factors and presenting clinical features that included safety risks, and severe symptoms of multiple psychiatric disorders including mood related disorder and substance use disorder that were associated with affective instability and impaired functioning, as well as the treatment failure at lower levels of care. The patient continued to require residential structure and monitoring until he had achieved stability with regard to the mood disturbance and was engaged in treatment for the co-occurring disorders with improved functioning with the remaining issues to include relationship and interpersonal functioning with authority figures, peers, and family, and continued need for clinically appropriate aftercare, as noted in the clinical summary.
He continued to display clinical features and symptoms that necessitated the continued residential level services as he struggled to engage in treatment and had intermittent bouts of affective instability that did require residential level structure and monitoring with active treatment. He had a history of treatment failure with lower level services and had displayed dangerous and problematic behaviors with maladaptive coping, emotional regulation problems, distress problems, interpersonal functioning problems and day-to-day functioning problems in the context of severe mood, disruptive and substance use disorders complicated by aggressive and violent behaviors. He continued to represent a safety risk and relapse risk, and could not have been effectively managed in a less restrictive treatment environment during the time interval under review through discharge.
Moreover, the monitoring, structure and intensity of residential services were medically necessary in keeping with prevailing standards of medical practice and the application of NY State Office of Alcoholism and Substance Abuse Services (OASAS) Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) 3.0 Criteria, referenced below.