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

The patient is a 16-year-old male who has had a steady increase in his school truancy, oppositional defiant behaviors and substance abuse (primarily with cannabis).  His family attempted to engage him in multiple levels of outpatient therapy but the patient has not cooperated and has failed to complete the recommended outpatient treatment. The patients behavior escalated to stealing his uncles car and he is now on probation.  Despite oversight from his probation officer, he continued to avoid school and is failing the 11th grade. The patient had recently started to have physical altercations with his father.  His mother reports that he spoke to her about suicide and the counselor at the program states that he has had thoughts of harming a peer.  On admission to the program this history was denied by the patient.  The records describing the course of treatment demonstrate the patient made excellent progress.  The patients family is actively involved, and the patient has accepted the 12-step program and become more engaged in school. He actively participated in the program for a total of approximately 6 weeks.  At the time of his discharge he was preparing to return to his public school and had made a commitment to sobriety with a change in his oppositional and defiant behaviors. The patients parent has requested reimbursement for the residential treatment services provided from March 2006 through May 2006. The Health Plan denied this request based upon a determination that the inpatient services were not medically necessary.The patients primary care provider had taken care of him for the two years prior to his admission to the residential treatment facility. The provider described a history of cannabis abuse, school truancy and school failure and arrest. Outpatient rehabilitation was unsuccessful due to the patients refusal to attend the sessions and submit urine samples and his eventual drop out from the program. The patient also rejected other attempts at treatment and his provider suggested a downward spiral based on parental reports of suicidal ideation. The admission evaluation at the residential treatment facility also stated the patient had failed lower levels of care, manifested suicidal ideation and possible homicidal ideation, had physical altercations with his father, was truant from school, was defiant, using drugs and stealing.  The patients psychological testing and projective testing results were indicative of anxiety, low self-esteem, sadness and anger.  There was also a theme of alcoholism. The patient was diagnosed with Major Depression, Oppositional Defiant Disorder and cannabis dependency.The progress notes while in residential treatment documented weekly individual sessions, weekly parent sessions, and weekly parenting classes. The patient was discharged in May 2006 with a showing of academic progress, no suicidal or homicidal ideations, and improved social interactions; weekly psychotherapy was recommended following discharge.  Utilization of the Adolescent ASAM criteria placed the patient at the residential level of care for substance abuse.  The program that he attended was certified for the treatment of substance abuse at the III.5 level of care.  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.