Appeal type: Medical Necessity
Decision: Overturned

The patient is a 13-year-old male referred to residential treatment by an educational consultant due to his inability to stay on topic, talking excessively, aggression towards peers, very rigid thinking with paranoid undercurrents, and escalating behaviors. He exhibited very obsessive thought patterns and rigid thinking. He was also noted as having difficulty with social cues and poor social relations. The patient was initially formally evaluated in 2004 at age 11 for much of the same, in addition to depression. His parents noted him as easily upset and having threatened to kill himself on several occasions, having little confidence, and being socially isolated and rejected by his peers. They also noted him as having considerable difficulty with impulsivity, restlessness, prone to acting without thinking and often forgetting to do things. Punishment did not change the patients behavior and he did not learn from his mistakes. The patient himself noted feeling frequently confused, having difficulty focusing, and that other people secretly controlled his thoughts. He often felt made fun of and rejected by other children, though also recognized that the things he did made others angry. He was receiving Zoloft at that time, though psychologic testing revealed him to be experiencing a very high level of depression. It also revealed a paradoxical quality involving a very high level of activity in conjunction with a very high number of indicators of depression, suggesting the presence of cyclic mood disorder. The patients mental status exam at that time showed him as quite fidgety, frequently spinning around in his chair, speaking almost constantly, asking questions that were overly personal or more self-revealing than typical of most children his age, and appearing to narrate every thought that went through his head. His comments were directed to the examiner but at times he appeared to be speaking to himself. He was also extremely silly at points, tending to repeat phrases in almost a stereotyped way. He laughed a lot at these times, seeming fairly giddy. The patient also demonstrated intermittent impulsivity in responding to test questions or in beginning activities before they had been fully explained. He also became fairly fixated on an idea or activity. At the point of his referral to residential treatment two years later his parents again reported him as not knowing how to appropriately interact with others, seeming unable to read facial expressions. He was also noted as tending to perseverate on various subjects such as cats, George Bush, history, or particular peers. During his intake evaluation, he wanted to talk about politics and human rights, becoming more aggressive as the discussion ensued. He quickly became highly agitated, yelling and ranting to the point that a security officer had to enter the consulting room.  His affect was anxious and labile. He had ideas of reference, some paranoid ideation, and bizarre thought content, asking, Are you going to behead me? He was also very talkative and exhibited pressured speech, though with very high verbal ability. He was controlling of the conversation, demanding, hypervigilant, and complaining. His judgment was viewed as poor, not recognizing his problems or what to do about them. Also of note was his enjoyment of annoying and antagonizing others.In terms of his treatment, the patient received a variety of therapies including medications. He first started with Depakote, and then added Risperdal, and finally Zoloft.  Despite an adequate valproic acid level the patients anger, impulsivity, and verbal pressure did not improve until the addition of Risperdal. Zoloft was later added due to residual anxiety and depression, but was eventually phased out in favor of Lexapro.  Throughout his residential stay the patient has been a challenge, having sizable difficulty with irritability, following rules, and accepting the consequences of his behavior.  A request has been made for reimbursement for the residential treatment services already rendered as well as authorization for continued treatment at this level of care. The Health Plan has denied this request indicating residential treatment is not medically necessary in this case.This patients operative diagnoses of Mood Disorder, NOS and Borderline Personality Features do not adequately reflect the severity of his pathology. From all that has been described, he appears to convincingly suffer from something akin to Aspergers Syndrome and/or Bipolar Disorder, with sizable grandiosity, lability, mood vacillation, and verbosity. The family history of Bipolar Disorder is not inconsequential in this regard. Based upon the patients history as well as the treatment notes, the depth of his pathology seems quite clear. This is so much so that only a highly structured environment would really be expected to be of help, away from his parents and where therapeutics can occur daily and with intensity. As such, residential treatment is medically appropriate and indicated in this case and is the only intervention that is likely to be of benefit. The patient should be re-evaluated by his treating psychiatrist on a monthly basis to determine if there has been significant improvement such that discharge to a lower level of care is appropriate.Based upon the information set forth above, I have determined the services at issue were/are medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.