Appeal type: Medical Necessity
Decision: Upheld

The patient is a 17-year-old male who was admitted to residential treatment in July 2005. At that time he had a history of manipulative behavior, showing no respect, breaking things around the house, and not following household rules. The patient was reportedly court ordered into residential treatment after being on probation for shoplifting. He apparently also ran away from home for 10 days around the same time.  The initial psychiatric evaluation was in July 2005 at which time the patient was diagnosed with possible mood disorder, attention deficit disorder, and substance abuse. The provider suggested additional testing to determine the need for medications (psychostimulants for ADHD versus an SSRI for a subdued mood). The follow-up evaluation was in August 2005 at which time Strattera was prescribed for ADHD. A follow-up visit was completed in August 2005 and Provigil was added. The next visit was reportedly in September 2005 at which time Seroquel was started for perceptual disorders felt to be secondary to prior hallucinogens and methamphetamines. The next follow-up was in October 2005 when the Strattera was stopped and the Seroquel increased. No additional follow-up is noted prior to the report dated January 2006. No other psychiatric progress notes were included in the submitted records.At issue in this case is whether residential treatment services were/are medically necessary for treatment of the patients medical condition.  Review of the submitted clinical records reveals an absence of any evidence of suicidal or homicidal ideation or activity prior to or at the time of admission. The only behaviors identified as risk-taking were associated with the patients drug abuse and running away (although no apparent adverse occurrences are noted from the latter). Additionally, it appears the patient had a supportive home environment conducive to engagement in treatment as well as engaged parents. Furthermore, there is no evidence of any intensive multidisciplinary outpatient treatment beyond the prior three-day per week substance abuse treatment programming. Moreover, the submitted documentation does not demonstrate the patient manifested a level of severity of illness that (based on nationally recognized guidelines from the American Association of Community Psychiatry (CALOCUS)) meets the level consistent with the need for residential treatment. The fact that there was poor patient engagement and a poor prior treatment response history indicates that an intensively integrated outpatient program would have been an appropriate placement option. This would include the involvement of multiple components within the system of care where services are delivered more frequently and for extended periods (See CALOCUS Version 1.5). Services at this level include partial hospitalization, intensive day treatment and home-based wrap around. Finally, it appears the patient has had a minimal level of psychiatric services, infrequent family therapy sessions (apparently mostly consisting of telephone conversations between the patient and his family) and infrequent individual therapy while in residential treatment. There is also no evidence of frequent treatment planning in the information provided.For the reasons 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.