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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for residential treatment center (RTC) services. Findings:  The physician reviewer found that although this patient was struggling significantly from autistic sequelae, and there was no evidence of prior treatment with trusted therapies for autism spectrum disorder such as social skills training and applied behavioral analysis, the records indicate that service delivery in a less restrictive setting would have been inadequate during the disputed timeframe. In this case, the patient had an illness burden that dated back to childhood. Her OCD and autism were complicated by co-occurring depression and anxiety. This is of particular relevance since it has been well-established in both clinical practice and the medical literature that anxiety ridden mood disorders are notoriously difficult to treat and in general have poorer outcomes. The patients psychiatric symptoms were impairing her daily routine and contributing to significant impairment across multiple domains of functionality, while also undermining her psychological development. Indeed, her struggles with self-concept, relationships and impulsivity were consistent with role diffusion and suboptimal individuation. The patient had pursued less restrictive treatment settings and complex pharmacotherapy, yet remained symptomatic. Her providers recommended residential placement consistent with the American Psychiatric Association (APA) recommendations. Discharging the patient earlier would have been inappropriate as she had not consolidated the treatment gains that prompted the admission. Her rigidity was hampering her adaptability. She started exposure response prevention, which is a first-line treatment for OCD. The patient was having success with goal completion. She also had better insight and improved willingness to engage in the therapeutic process. The patient was prescribed a pro-serotonergic medication, fluoxetine, for increasing anxiety and excessive worry. In sum, the patient actively engaged evidence-based treatments with good success. The services and setting were safe, appropriate and consistent with good practice, while the duration of treatment for a case of this severity and complexity aligned with community standards and more importantly facilitated a smooth transition to a less restrictive setting. Additionally, the services provided at the time were reasonably expected to improve her condition and prevent a more serious episode of illness. Considering the clinical presentation and the current peer-reviewed medical literature, the RTC services provided during the dates of service in question were medically necessary for treatment of the patients behavioral health condition. Final Result: The reviewer determined that the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be 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.