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

The patient is a 17-year-old male previously diagnosed with oppositional defiant disorder, dysthymic disorder, alcohol abuse, cannabis abuse, and parent-child relational problems, admitted to residential treatment in May 2005 at his parents request due to his behavior at home, replete with anger, defiance, dwindling academic performance, and poor choices in peer relationships. He was also smoking marijuana and drinking alcohol, perceiving neither as a problem. The patients perspective was that he was hanging out with the wrong crowd, drinking alcohol, and smoking pot. His parents were concerned that he was going to get in trouble with the law or get hurt in a fight. Parenthetically, the patient was without any prior history of infractions of the law or arrests and had no history of physical fighting. He reported using marijuana over the past four years estimating his usage of the two combined at about two to four times per month. He also spent nine weeks in a wilderness program prior to his entrance into residential treatment. Although the patient had reported past problems with bulimia and cutting on himself, these were quiescent when he was admitted to residential treatment.The admission mental status exam described the patient as pleasant and cooperative. His speech was of normal rate and tone. His thought content was without hallucinations, delusions, suicidal, or homicidal ideations. His mood was mildly depressed. IQ testing revealed a full scale IQ of 146, with a verbal IQ of 150 and a performance IQ of 130. The record reflects only one evaluation by a psychiatrist at the time of admission, and thereafter he was seen by a psychiatric nurse practitioner. The patient received no psychiatric medications during his stay but was treated with a number of therapies. Throughout his confinement, the documentation points to a mood that was pretty good and behavior that was really unproblematic. The patient was described as frequently conveying feelings of superiority and entitlement, though these did not manifest as particularly egregious behavior. He eventually softened in his perspective of drug use and admitted that it may be problematic.  The Health Plan denied authorization and coverage for residential treatment services based upon their determination that the services were/are not medically necessary.Although the patient evidently suffers from Narcissism, which has driven his rebelliousness and the use of marijuana and alcohol, his pathology is not that far beyond the pale of what a very bright adolescent might exhibit.  His high IQ is undoubtedly not coincidental, in this regard.  The record is strikingly lacking in notations of significant pathology or anomalous behavior because it is unlikely there was much to be evidenced.  The patient was not truly depressed and his drug and alcohol use were relatively infrequent.  As such, a wide variety of treatments in the outpatient realm could have been entertained.  His behavior was alarming and annoying to his parents but to conclude that this patent needed residential treatment is a reach.  His behavior is characteristic of many bright and rebellious adolescents and residential treatment was not warranted because the rebelliousness was difficult to manage in the home environment.  Based upon the information set forth above, I have determined the services at issue were/are not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.