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

The patient is a 44-year-old male with Schizoaffective Disorder, admitted to a partial hospitalization program in August 2006, due to persistent depression and his belief that he was in need of custodial services due to progressive weakening of his legs. The patient was noted as chronically quite depressed, isolative, emotionally blunted, and very somatically focused.  In terms of the latter, the patient felt that since spraining his right ankle two-and-a-half years earlier, he had experienced progressive difficulty ambulating and had more recent weakness of his hands. Though he underwent an extensive workup, apparently inclusive of MRI scans of his spine, no definitive cause for the weakness was discovered. Nonetheless, his admission physical exam was notable for some atrophy of thenar muscles bilaterally, weakness of interosseous muscles, weakness of hip flexors and extenders, and inability to dorsiflex or plantar flex both feet, with bilateral foot drop and some ataxia in gait. Cervical myelopathy was considered, as was muscular dystrophy in the differential diagnosis of these findings. As for his psychiatric treatment, he was noted to be extremely withdrawn, often complaining of fatigue, and involving himself only scarcely in group therapies. From a pharmacologic standpoint, he was treated with Lexapro 20mg a day and Risperdal 3mg a day, the latter eventually increased to 3.5mg a day. Wellbutrin 150mg twice a day was later added. Inasmuch as there was legitimate reason to be concerned about the patients weakness having a genuine neurologic underpinning, much of his lethargy and perceived inability to care for himself was felt to be of psychiatric etiology.   At issue is whether continued partial hospitalization services were medically necessary beyond September 2006.Review of the submitted progress notes indicates the patient had not begun to show improvement as of September 2006. Given how passive, withdrawn, depressed, and somatically focused the patient was, alongside documentation of his later improving to some extent, it was medically appropriate for the patient to continue at a partial hospitalization level of care beyond September 2006. Group therapists have been working assiduously with him to challenge many of his struggles and beliefs, and his psychiatrist has also been adjusting his medications. In cases such as this the goals of treatment are to allow, if not enforce, a greater degree of socialization and independence, and transcend the somatization, some of which borders on frank delusion. In order to attain such goals, continued treatment at a partial hospitalization level of care is needed. All told, there is a clinical indication in this case for continued partial hospitalization services. Therefore, I have determined the requested services are medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned. The patient should continue at a partial hospitalization level of care for another 30 days. Following the 30-day period the patient should be re-evaluated to determine if he can be transitioned to a lower level of care.