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

A review of the medical records from the inpatient hospitalization and the residential treatment facility reveals that the patient is a 19-year-old male who entered an inpatient level of care in March 2006 after being transferred from a mental health clinic near where he attends college. The patient was in an altered state of consciousness and felt to be a danger to himself on admission to the facility. He was admitted on a 5150 hold and remained at this level of care until April 2006. The description of his mental status on admission was that he was giggly and disoriented.  Prior to admission he became assaultive and needed to be given IM medications to control his behavior. The history prior to admission was that the patient experimented with marijuana and other drugs while at college.  He reports using LSD, cocaine, Ecstasy and alcohol.  The evaluator felt that the patients manic state with psychotic ideation and delusions was drug induced. Geodon was started on his admission to inpatient treatment.  The review of the hospital progress notes reveals that by the end of March 2006 the patient was stable with no manifestation of hypomania or delusions.  He was still ambivalent about entering treatment for substance abuse. The hospital felt that the patient needed RTC Level III.7 rehabilitation for substance abuse due to his psychiatric impairment and his denial of the consequences of the continuing use of drugs. The patient was transferred to a residential treatment facility in Montana as a direct transfer from the hospital. Records from the residential program in Montana indicate the patients date of admission was April 2006. His mental status on admission revealed that the patient denied the need to be at this facility. He revealed that prior to admission he had used cocaine 12-15 times, Ecstasy, methamphetamine, mushrooms, and marijuana daily for one year.  His mental status revealed that he was cooperative, oriented, with no indications of suicidal ideation, homicidal ideation or a thought disorder or hypomanic behavior. He was assessed on admission as at a Level III.7 level of care. The family history was significant in that his biological father has been incarcerated for chronic substance abuse.  The patient reported sharing cocaine with his father.  The patient requested to stop his antipsychotic medications and these were discontinued a few days after his admission.  He participated in a 30-day program and was discharged to a community based program near his parents home.  At issue is whether inpatient services were medically necessary beyond March 2006. Also at issue is whether the patients residential treatment stay from April 2006 to May 2006 was medically necessary.Regarding the patients inpatient hospital admission to a dual-diagnosis unit, he appeared to be ready to step-down to a lesser level of care after March 2006.  He did not manifest any signs of withdrawal or biomedical conditions. In addition, the patient was stable with his mental status examination and medications were also stable with no changes. As such, the patient did not require an acute inpatient level of care after March 2006.With regard to the patients admission to a residential treatment level of care in April 2006, he presented with the following ASAM criteria: Dimension 1:  No withdrawal;  Dimension 2:  No biomedical conditions;  Dimension 3:  History of a bipolar condition possibly substance induced, stable on medications, plan to discontinue antipsychotic medications while monitoring;  Dimension 4:  Despite serious consequences still in denial;  Dimension 5:  Relapse potential high;  Dimension 6:  Recovery environment supportive.  As such, the patient met Dimension 3, 4 and 5, and his admission to this level of care was appropriate.  Within the first week of his admission his medications were discontinued and he was not experiencing side effects of a psychiatric or behavioral nature. Hence, the patient no longer met Dimension 3 criteria after the first week of his admission.  At this point in time the patient was able to step down to a partial hospitalization level of care.  The initial week of observation with the discontinuation of his anti-psychotic medications meet the need for intensive monitoring due to his recent psychotic episode. However, as of April 2006 the patient was able to utilize a lower level of care and continued residential level of care was no longer medically necessary.In conclusion, the submitted documentation demonstrates continuing care at the acute inpatient level of care was not medically necessary after March 2006. The documentation supports the medical necessity of the patients admission to a residential level of care in April 2006. As of April 2006 the patient no longer met criteria for continuing residential level of care. Therefore, the Health Plans denial should be partially overturned.