Appeal type: Medical Necessity
Decision: Overturned

The patient is a 16-year-old female who had been in treatment with mental health providers within the Health Plan prior to her admission to the non-Plan acute inpatient psychiatric facility for comprehensive evaluation. The evaluation was prompted by the patient stealing money from her aunt and also having a disassociative/transient psychotic episode. The patient also had recently disclosed that she was sexually molested when on visitation with her father by a perpetrator with whom she was left alone. The patient lives with her biological mother and step-father. There continues to be some interaction and visitation with the biological father. There is continued conflict in the relationship between her biological parents.The patients admission to the adolescent unit of the acute psychiatric facility included an initial assessment period of three weeks with intensive individual, group and family therapy sessions. Medication management was initiated with a significant decrease in the patients symptoms of depression. At the end of the three week assessment period, the facility then recommended that the patient remain and continue with their program. The parent has requested reimbursement for the non-Plan acute inpatient psychiatric services provided from June 2006 through July 2006. The Health Plan denied the request based upon a determination that the services were not medically necessary.The patient had been receiving outpatient psychotherapy within the Health Plan for several years but the disclosure of sexual abuse did not emerge during the course of her treatment. While the patient was not suicidal or homicidal prior to her acute admission, the disclosure of sexual abuse along with the transient disassociative episode created a crisis that placed the life and functioning of the patient at risk. To seek independent, acute inpatient psychiatric care specific to the needs of an adolescent was a prudent and reasonable response. The initial three weeks of evaluation at the acute inpatient psychiatric facility were comprehensive and appeared to be helpful for the patient. However, the focus on individual psychotherapy did not continue after the initial three week evaluation though there remained many unresolved issues. Following this comprehensive assessment period, continued treatment including weekly individual psychotherapy, family therapy and survivor group therapy could have been provided in the patients home community. If the necessary services were not available within the Health Plan, the Health Plan could have augmented the patients treatment with local outside resources as part a comprehensive treatment program. In summary, although there patient did not present with suicidal or homicidal ideation or a thought disorder, the disclosure of sexual abuse and a disassociative episode in an adolescent is an indication for a comprehensive evaluation at the acute inpatient level of care. The initial three weeks of inpatient services were medically appropriate and should be covered by the Health Plan. It was not however, necessary for the patient to remain at the non-Plan facility after July 2006 as her care could have been managed by the Health Plan within her home community.Based upon the information set forth above, I have determined a portion of the services at issue were medically necessary for treatment of the patients medical condition. The Health Plans denial should be partially overturned.