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

The patient is a 17-year-old male with a history of ADHD, polysubstance dependence, oppositional defiant disorder, and narcissistic traits. He was admitted to residential treatment in September 2004.  He had been substance dependent for the past five years, involved primarily with marijuana and alcohol.  Admission was considered necessary due to the patients persistent aggressive behavior at home.  The behavior involved physical aggression in the past, but immediately prior to his admission it consisted of verbal abuse and violation of household rules.  The patient is also noted to have felt depressed for years.  Overall, the patients perception of his behavior was Do drugs, hit them, and dont listen.  Family dynamics included an overly permissive mother who rationalized the patients behavior and a fundamentally uninvolved father.  Reportedly, there was marital discord with some parental hostility directed toward the children as well. The patient was unsuccessful at boarding school and a 12-week wilderness program just before his residential treatment admission, had no apparent measurable impact on his behavior.  From a treatment standpoint, the patient was maintained on clonidine, Concerta, and Effexor. Effexor was later discontinued. Throughout the patients attendance at school and various group therapies he was noted as being rude, insensitive to others, cocky, and defensive.  He had a seeming inability to withstand or incorporate feedback regarding his behavior.  The patient had numerous uncompleted assignments and as a result was failing in school with a GPA of 1.17.  The patient demonstrated no obvious concern about his paltry performance.  His behavior in school was described as uncooperative and non-participatory.  The patient and his parents had almost no positive interaction during their visits.  Review of the submitted records points to the patient having had significant difficulties in his mood and concentration, eventually leading to a change in his medication. The last regimen, consisting of Strattera, clonidine, and Provigil, seemed to help substantially more than the prior regimens of Concerta and Abilify.At issue in this case is whether residential treatment services were medically necessary from September 2004 onward.Given the clear documentation of the patients egregious behavior, a diagnosis of conduct disorder may be more appropriate than oppositional defiant disorder. Residential treatment was medically indicated because it is unlikely that outpatient services would be adequate or appropriate given the state of the patients parental relationships and his parents inability to control his behavior.  He had failed outpatient treatment, his behavior was worsening, there were concerns of his being depressed, and his parents relationship was quite unstable. Review of the submitted notes point to the patients depression and ADHD as quite flagrant, though he eventually responded to the change in Straterra and Provigil. His abysmal performance in school lends support to the notion of his depression and/or ADHD as quite operative and very problematic. It would not be reasonable, therefore, to expect the patient to navigate through this as well as maintain sobriety and follow rules while at home. This is particularly true since his parents were noted as consistently problematic during his residential stay. However, it does appear as though the patient finally improved enough, and in a consistent way, by the end of September 2005 to allow for transition out of residential treatment to an out-of-home placement. As such, I have determined that the residential treatment services at issue were medically necessary until September 2005. Therefore, the Health Plans denial should be partially overturned.