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Patient Information

The patient was a 16-year old male with a dual diagnosis of substance use disorder (SUD) co-morbid with depression and anxiety.

Provider Information

Services were rendered to this patient at an adolescent residential treatment center located in Utah, from May 1, 2008 through December 19, 2008. The total charges for his treatment were $125,421.00. The family’s insurance, Blue Cross of California, denied payment for the patient’s entire stay, citing that behavioral health medical necessity criteria were not met for admission to the Adolescent Psychiatric Residential Treatment Center. They maintained that the patient demonstrated the ability to be managed at a less restrictive level of care, such as psychiatric outpatient treatment.

History of Patient’s Condition

The patient had a history of mood disturbance, anxiety, poly-substance abuse, disruptive behavior, conflicts with parents, and school failure beginning in the 8^th grade. His history was positive for a traumatic event occurring at that time, and was associated with the significant anxiety and mood disturbance that ensued. Substance abuse began after this event and increased in severity over the years. The patient had multiple relapses and a history of high risk behavior. He abused substances such as marijuana, ecstasy, angel dust, and PCP.

Treatment for this patient included an outpatient psychiatrist from 2007 to 2008, which included individual and family therapy, as well as medication management. During outpatient treatment, the patient’s behavior continued to decline. He became suicidal and violent and ultimately required acute psychiatric hospitalization for two weeks. Upon release, he was placed in a wilderness program for nine weeks. Diagnoses there included Oppositional Defiant Disorder, Major Depressive Disorder, and Marijuana Dependence. During his stay in the wilderness program, he required substantial supervision and was felt to be at significant risk for relapse and placing himself at physical risk. Upon completion of the wilderness program, residential treatment was recommended.

Throughout treatment, this patient had been treated with medication including Lexapro and Lithium.

Reason for Referral

The family’s insurance provider denied payment of the patient’s entire confinement in the adolescent residential treatment center in Utah, citing medical necessity criteria not met. The insurance provider claimed the patient demonstrated the ability to be managed at a less restrictive level of care, such as psychiatric outpatient treatment.

Claim Evaluation and Document Needs

We gathered the documents needed to address a continued stay medical necessity denial. Such documents included records from the adolescent residential treatment center in Utah, a copy of the plan booklet from Blue Cross California, the clinical criteria used by the said claim payer to determine medical necessity, letters of medical necessity from prior treating providers, including an inpatient wilderness program, and various medical records.

Barriers to Overcome

We needed to convince the claim payer with medical record documentation and supporting letters that the patient was taking unnecessary risks or doing potentially lethal things that required medical intervention and containment in a 24-hour sub-acute treatment setting. We needed to provide evidence that psychiatric outpatient treatment was insufficient and that treatment at the adolescent inpatient level of care was required to restore the patient’s previous level of functioning.

Appeal Process

A formal standard written appeal letter was sent to the payer within 180 days (as required by most health plans and ERISA) of the denial date listed on the first denial letter.

The appeal letter outlined the patient’s history of present illness and provided evidence that he met requirements for admission to inpatient residential treatment due to his symptoms and behaviors, as quoted in the Plan’s Life and Health booklet under “Serious Emotional Disturbance of a Child.” We also highlighted that his admission to the adolescent residential treatment center was characterized as medically necessary by his treating physicians. In doing so, we provided clinical documentation in support of his admission at this level of care. Specifically, we included a letter of medical necessity (LOMN) from the psychiatrist who treated him in 2007 and 2008 which substantiated that although the patient was treated with a “combination of medication management, relaxation therapy, individual and family psychotherapy, and exploration into and development of various modes of academic assistance in order to try to stabilize the situation,” he continued on a downward course that included continued abuse of street drugs and deterioration to the point where he became suicidal and violent and required two weeks hospitalization. The psychiatrist continued to note that the patient would not be able to heal without an extensive change of milieu. It was the psychiatrist’s recommendation that the patient attend the wilderness program.

We also included a letter of medical necessity (LOMN) from the wilderness program which stated that during the course of his assessment the patient required substantial supervision in order to not manipulate his parents and other adults, make unhealthy decisions regarding his substance dependence, and give in to his intense desire to be accepted by others around him. Due to his depression and his willingness to put himself at physical risk, it was recommended that he be placed in a “residential therapeutic environment to meet his complex long term needs and to further reinforce new skills in all areas of growth.”

We also included portions of the Treatment Notes from the adolescent residential treatment center in Utah which stated that a less restrictive setting would be inappropriate for him because he required the structure and safety provided in this particular treatment environment. The patient had struggled throughout his treatment at the RTC and had multiple relapses, including getting intoxicated from a bottle of Listerine. He had also accrued several safety violations, one of which was an AWOL attempt.

Final Outcome

Upon receipt and review of the initial appeal letter, the insurance payer’s utilization review management department maintained denial stating that after reviewing the information provided, the patient was not showing current behaviors which included self injurious and/or uncontrolled risk taking with potentially lethal consequences that require containment in a 24-hour sub-acute treatment setting. They maintained that the patient met criteria for a lower level of care, such as intensive outpatient treatment.

Only one level of appeal was required under this plan to exhaust the administrative appeal remedies. Since this process was completed, it was decided to send a request to the State of California (which is where the patient resided) for consideration of the independent medical review process. A letter was sent to the State of California, within 60 days (each State has a different timely filing period) of the denial date on the second denial letter. Maximus, through The Center for Health Dispute Resolution, accepted the case for full review in November, 2008.

In early January 2009, after a full review of the appeal, the external review company, Maximus, fully reversed the decision rendered by Blue Cross of California. This reversal authorized payment of the patient’s claims, up to the Plan benefit of 100 days per calendar year.

Claim Payment

Although the State of California external review program overturned the Blue Cross of California denial in January of 2009, the insurance only agreed to pay the claims from May 1, 2008 through August 8, 2008 stating that the family met their calendar year benefit of 100 days for residential treatment on August 8, 2008. Payment of $37,700.00 was made for payment of the 100 days of certified covered care.

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