Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Anxiety, depression, obsessive-compulsive related disturbances and problematic behavior associated with substance abuse.
Treatment: Continued Partial Hospital Mental Health Treatment for Children And Adolescents.
The insurer denied the Continued Partial Hospital Mental Health Treatment for Children And Adolescents. The denial is overturned, in part. 

The patient is a male referred and admitted for partial hospital program (PHP) level mental health treatment to address persistent symptoms of anxiety, depression, obsessive-compulsive related disturbances and problematic behavior associated with substance abuse with cannabis, alcohol, and other substances of abuse, and associated with high risk and self-destructive behaviors. 

The patient patient's clinical course became severe with problematic behavior resulting in parent-child relational problems and impaired functioning with regard to functioning within the family constellation and social environment with peers. The patient repeatedly had impulsive high-risk behaviors including substance use with cannabis and alcohol as drugs of choice, and history of aggressive and self-harming/destructive behavior. The patient has had ongoing issues with self-esteem, confidence, and relationship problems, especially within the family constellation and with peers. He has engaged in self-destructive or aggressive behavior and violation of boundaries within the social and home and school environment. 

Prior to the patient's admission, he had participated in a Wilderness Program for approximately six months and had received residential level services. Thus, his admission to partial hospital program (PHP) level care with boarding was a step down from residential treatment with diagnoses of a mood disorder, obsessive-compulsive disorder, cannabis and alcohol use disorder, social anxiety disorder, and parent-child relational problems in the context of past consideration of bipolar or unipolar depressive disorders and body dysmorphia. 

Initial evaluation upon admission for PHP care had revealed a mental status examination that was free of severe psychiatric symptoms such as a psychotic disorder despite chronic auditory hallucinations, frank mood cycling, formal thought disorder, cognitive impairment or suicidal ideation. The patient was described as having limited insight, impaired judgment and poor impulse control. Mood was dysphoric and irritable with persistent irritability and affect was anxious and angry together with a history of argumentative behavior or other behaviors that were high risk or self-destructive in the context of emotional dysregulation and impulsive behavior triggered by being slighted or offended.

The patient had no significant acute general medical conditions. Chronic conditions included dyslipidemia and diabetes mellitus and allergies with associated treatments. His psychotropic regimen included Latuda, Pristiq and Intuniv at therapeutic dosages, as well as melatonin.

The patient is supported in his treatment effort by family. Stressors included primary support, educational, social environment, and other psychosocial domains.

The patient underwent comprehensive psychiatric evaluation including review of past psychological testing and treatment records in order to affirm the diagnoses. He received safety monitoring and treatment planning that included therapeutic interventions to improve coping skills and other interventions to address the substance use disorders with regard to maintaining abstinence. The treatment plan included the goals of improved coping; breaking the cycle of self-destructive behaviors; and the development of healthy relationships. Individual, group and family therapies were provided throughout the course of treatment including dialectical behavioral therapy (DBT). The program focused on organizational skills; self-care; peer relationships; and life skills, as well as behavioral and emotional regulation with stress management, cognitive behavioral or dialectical behavioral techniques, and sessions to address family functioning and dynamics. 

The patient actively participated in the treatment plan and worked on therapeutic-recreational, neurodevelopmental, social, and emotional functions in the context of a residential setting with PHP level programming on weekdays (five-days per week) with boarding and structured supervision.

The patient struggled to settle into the new treatment setting after a prolonged stay in another program. The patient remained depressed and irritable with affective instability and thoughts of aggression with respect to peer relationships and with persistence of family issues and the underlying mood disturbance. The patient remained depressed and was not doing that well overall with continued relational problems, distress, sleep disturbance, and disabling anxiety and dysphoric irritability with reports of hearing voices telling him to hurt others. There was a question of whether he had a factitious disorder which was ruled out. He was maintained on medication with the goal of tapering or stopping the Intuniv and Latuda. He had displayed problematic episodes of conflict with a peer and confrontational family sessions that ultimately resulted in better tolerance and coping with relationship issues. 

Going forward, the patient gradually became more appropriate with regard to behavior and social interactions. He was increasingly engaged in group sessions and more appropriate with activity therapies. He was noted to be developing better coping skills with improvements in emotional regulation. The treatment plan called for continued goals of improved coping; breaking the cycle of self-destructive behaviors; and the development of healthy relationships while addressing core symptoms related to his psychiatric co-morbidity and parent-child relational problems. Individual, group, and family therapies were continued with intensive and active treatment, safety monitoring and structure to address the residual emotional dysregulation and mood disturbance that persisted. He had not shown drug withdrawal symptoms or biomedical complications related to the substance use disorders and remained sober, and he was abstinent from substances of abuse. He continued to require intensive treatment for the affective instability associated with his mood, anxiety, and obsessive-compulsive related disorders, and attended to problematic family issues with family-focused sessions. The patient showed modest progress with treatment goals and was more appropriate in family sessions. The treatment plan and therapeutic interventions were designed to make definitive progress with improved mood, diminished anxiety/irritability and better functioning with regard to peer relationships, as well as activity therapies and other tasks to improve life skills. 

Again, the program focused on organizational skills; self-care; peer relationships; behavioral and emotional regulation with stress management, cognitive behavioral or dialectical behavioral techniques, and continued sessions to address family functioning. The patient remained in the program with PHP level treatment  and records reflect the discharge plan that called for the patient to receive continued mental health and substance-related treatment including family focused sessions with continued use of medication.

Yes, in part, the proposed PHP level treatment was medically necessary. 

The Continued Partial Hospital Mental Health Treatment for Children and Adolescents, including boarding with monitoring and other services noted in the clinical summary could not have been safely or effectively provided at a lower level of care. The continued treatment of this patient's co-occurring disorders did continue to require the structure of a PHP setting and the monitoring due to safety concerns and the need for intensive treatment and structure provided for the duration of treatment. The patient continued to have behavioral problems related to his multiple mental disorders in the context of questionable insight and judgment, and a lack of coping skills in the context of severe psychosocial stressors including problems within the family constellation and peer problems triggering aggressive impulses. Thus, the PHP level structure and boarding with monitoring were warranted for the time frame under review until the time which the patient could have reasonably been expected to continue in treatment at a lower level of care. The patient had reached the point in his treatment episode that he could have stepped down to lower level services; he displayed no serious disturbance of mental status or safety concerns that warranted the continued PHP level structure and monitoring. 

This answer is consistent with the scientific literature and American Society of Addiction Medicine (ASAM) Criteria, as referenced below, as well as New York State Level of Care for Alcohol and Drug Treatment Referral Guidelines/Criteria, referenced below.

The patient's mental health treatment could not have been safely or effectively provided at a lower level of care as noted above. The patient's severity of mental health and substance use disorders together with the presenting clinical features at the time of step down warranted the continued PHP level services. However, when the patient no longer displayed any symptoms or had treatment issues or posed continued safety concerns that would warrant PHP level services or require PHP level management, programming and monitoring, could have been provided, as clinically appropriate, at a lower level of care in a less restrictive treatment setting and environment in keeping with prevailing standards of care and consistent with the application of New York State Level of Care for Alcohol and Drug Treatment Referral Guidelines/Criteria, referenced below. 

In summary, the patient's presentation and clinical features of the co-occurring mental disorders and substance use disorders did warrant the intensity of PHP level services and structure and monitoring up to the specified date, but did not warrant the intensity of continued PHP level services or programming or structure or monitoring beyond the specified date, in keeping with prevailing standards of clinical practice and New York State Level of Care for Alcohol and Drug Treatment Referral Guidelines with regard to the substance use disorders, referenced below, and is consistent with American Society of Addiction Medicine (ASAM) Criteria and scientific literature, also referenced below. 

Note: While the health plan indicates that a higher level of care is clinically appropriate; the PHP level care with boarding served the purpose of averting the need for a higher level of care until which time the patient could have been stepped down to a lower level of care-as noted above. Thus, the PHP level structure and boarding with monitoring were warranted for the time frame under review until the time which the patient could have reasonably been expected to continue in treatment at a lower level of care. The patient had reached the point in his treatment episode that he could have stepped down to lower level services; he displayed no serious disturbance of mental status, or safety concerns that warranted the continued PHP level structure and monitoring. Thus, PHP services were not medically necessary beyond the specified date in this case scenario.