Appeal type: Medical necessity
Decision: Overturned

This is a patient referred for residential mental health treatment to address behavioral disturbances in the context of mood, anxiety, and co-occurring substance use disorders associated with impaired functioning and aggressive and violent behavior. The patient was diagnosed with moderately severe and unspecified depressive disorder; generalized anxiety disorder and, severe to moderately severe substance use disorders with stimulant, alcohol, cannabis, hallucinogen, inhalant, anxiolytic and tobacco class substances of abuse. Additionally, the patient was diagnosed with attention deficit hyperactivity disorder (ADHD), posttraumatic stress disorder, and kleptomania. 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, anxiety and trauma related symptoms together with a history of impulsive aggression and violence toward family members and property, social withdrawal, school failure/refusal, and mood instability associated with substance use with daily continuous use of alcohol and other substances of abuse, as noted. The patient was referred to the residential treatment in order to address the problematic behaviors and core symptoms of depression and relationship problems including parent-child relational problems and his lack of motivation and the severe substance use disorder with cannabis.
The patient has a history of outpatient treatments without sustained benefit. There has been multiple suicide attempts with overdose, hanging or cutting, and violent and aggressive behavior related to anger and impulse control problems. The patient has conflict with parents that did include lack of motivation and problematic behavioral disruptions that included violent behavior and the abuse of tobacco, alcohol and cannabis and other substances.
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. Mood was dysphoric and irritable, and, affect was anxious together with a history of problematic behaviors that included academic failure and conflict with parents, and other behaviors that were self-destructive or reflective of severe mood disturbance including social withdrawal and self treatment with substances of abuse. 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 superficially 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.
The patient is supported in his treatment effort by family. The patient is a student, but had failed academically and had withdrawn from peers. There is a trauma history that includes rape while in the 6th grade and gang violence in which the patient was beaten. There is a family history of mental disorders and substance abuse reflecting genetic predisposition.
The patient was referred and admitted to the residential Program . He 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 other therapeutic activities, as well as other interventions aimed at improving life skills and coping while maintaining abstinence from substances of abuse. The patient actively and intermittently participated in the treatment 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 ongoing medication management.
The patient struggled with treatment and was openly disrespectful to peers and staff requiring direction and monitoring for safety. Medications were adjusted and included a regiment of Pristiq, Seroquel, clonidine, and Deplin. He was not violent or suicidal. He remained depressed and anxious with restlessness, apprehension, nervousness, tension, irritability and sleep disturbance including nightmares. He reported other trauma related symptoms including flashbacks and avoidance. He was somewhat grandiose and defiant in his stance. His insight was limited and judgment impaired with poor control of impulses and urges to self-harm.
He was noted to slowly gain insight and showed improved 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 that was modest and uneven. 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.
Case records or notes through 10/02/2019 indicate that the patient was noted to increasingly be more at ease with peers and staff, and better engaged with group and individual and family sessions with intermittent bouts of disrespectful behavior and oppositional behavior and social isolation. He worked on 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 on angry impulses that persisted. He achieved mood regulation and was noted to be euthymic and became better motivated to participate in treatment including involvement in peer supported groups and other therapeutic interventions to support abstinence from substances of abuse. The correspondence and case notes indicates that he steadily participated in mental health services with better functioning and improved mood. He was at risk for regression. Again, the treatment team recommendations for clinically appropriate aftercare were to have continued involvement with intensive and structured therapy, as well as psychiatric aftercare and efforts to sustain abstinence from substances of abuse.
The case summary including records, health plan documents, appeal documents, and correspondence from the health plan and patient representative, as well as the health plan's case notes, and rationale for the denial of certification for coverage of the requested treatment, were reviewed. This review is NY State mandated in consideration of NY State Office of Alcoholism and Substance Abuse Services (OASAS) Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) 3.0 Guidelines.
The health plan's determination is overturned.
The patient's admission and continued residential level treatment is reasonable and in the best interest of the patient. He continued to display clinical features and symptoms that necessitated 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 recently displayed significant problematic behaviors with maladaptive coping, emotional regulation problems, impulsive aggression with violence, distress problems, interpersonal functioning problems and day-to-day functioning problems that included academic failure in the context of severe mood, anxiety, attention and trauma related disorders and substance use disorders complicated by attention deficit hyperactivity disorder (ADHD) and impulsivity. He continued to represent a safety risk and relapse risk, and could not have been effectively managed in a less restrictive treatment environment for the dates of service under review. 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 OASAS LOCADTR 3.0 Guidelines, referenced below.