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Patient Information

The patient was a 16-year old female with a diagnosis of Mood Disorder NOS, Parent/Child Relational Problem, Oppositional Defiant Disorder, Alcohol Abuse, and Cannabis Abuse.

Provider Information

Services were rendered to this patient at an adolescent residential treatment center located in Utah, from February 18, 2008 through March 25, 2009. The total charges for treatment were $201,025.00. The family’s insurance, Blue Cross of California, initially quoted unlimited benefits and then sent a letter dated February 21^st, 2008 which denied coverage for the patient’s stay at this facility, citing no medical necessity.

History of Patient’s Condition

The patient had a long history of behavior problems, relationship issues, self harm, substance abuse, academic problems, sexual promiscuity, and mood issues. Her parents divorced when she was five and she lived with her mother until the age of 13. She reported neglect, as well as physical, emotional, and verbal abuse from her mother. The patient was also sexually abused on three different occasions; the first when she was nine, the next at twelve years of age, and another time since then. At the age of nine she was sexually abused by her mother’s boyfriend, who is now in prison for this crime. The patient had impaired sleep, nightmares, and anxiety as a result of this abuse.

The patient’s drug abuse began at the age of twelve when she started using alcohol and smoking cigarettes. At thirteen, she began using meth and cocaine every day, and indicated that she was an IV drug user. She also experimented with prescription pills, mushrooms and acid. The patient exhibited further self-harming behavior with respect to her sexual history. She had primarily unprotected sex with thirty-six partners.

Treatment history for this patient included two prior residential programs, one at a wilderness school for troubled teens in Oregon, and the other at a boarding school in Arizona. In June, 2007, the patient was placed in the wilderness school after having run way from home on three occasions. She had also been self-mutilating, lying, and experiencing mood issues; and, she was suspended from school twice for fighting with peers. In late August of 2007, after four suicide attempts at the wilderness school, she was transferred to a therapeutic girl’s boarding school. She spent approximately 6 months there before being transferred to the adolescent residential treatment center in Utah in February of 2008. It was believed that her worsening disruptive behaviors and self harming behaviors – cutting and suicidal thinking - necessitated increased structure and supervision that the treatment center in Utah could best address and treat.

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 that their internal residential medical necessity criteria had not been 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 medical records from the wilderness school in Oregon, the boarding school in Arizona, and the adolescent residential treatment center in Utah, a copy of the plan booklet from Blue Cross California, the clinical criteria for residential level of care used by the said claim payer to determine medical necessity, letters of medical necessity from prior treating providers, and various other medical records and testing.

Barriers to Overcome

We needed to convince the claim payer, through psychiatric record documentation and supporting letters of medical necessity, 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 an adolescent inpatient residential 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 claim payer in August, 2008, 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 attempted to provide evidence that she met requirements for admission to inpatient residential treatment due to her continued and worsening symptoms and behaviors. We highlighted that her admission to the adolescent residential treatment center was characterized as medically necessary by previous treating physicians. In doing so, we provided clinical documentation in support of her admission at this level of care. Specifically, we included a letter of medical necessity (LOMN) from the Program Director at the boarding school who stated that the treatment team at his academy made the decision to transfer the patient to a more structured environment because she required a higher level of care and clinical assistance. The patient’s therapist at the academy stated that “it is premature to discharge the enrollee at this time and would be against medical advice as she has not resolved significant issues, but is on the path to do so.” He further stated that the possibility of “returning to her prior conduct of drug use, self-harm, and illegal behavior” were “real risks and could lead to potentially life-threatening problems.”

We also included notes from the patient’s first several months at the adolescent treatment center in Utah. Documentation from The Self Harm/Suicide Risk Screening highlighted the patient’s risk for self-harming behaviors. These notes stated that the patient “has cut and attempted suicide in the past usually after fights/issues with boyfriend or mother.” And, the patient “held gun in mouth four times but did not go through with it. On two occasions she tried to hang herself, but did not go through with it. She used pills and alcohol.” We also presented notes from The Self Harm/Suicide Precautions Flow Sheet which showed that the patient was still at serious suicide risk. The notes stated that “she was planning on trying to hang herself in the bathroom during the night.” Additional notes from the Physician’s/Nursing Progress Notes stated that the patient “was on unit restriction for self-harm precautions. She had cut superficially on her extremities” and was not allowed to leave the unit. Documentation from the monthly treatment notes maintained justification for continued RTC treatment by stating that “until she not only significantly changes her behaviors, but also demonstrates substantial insight into her previous behaviors, she will be at high risk for relapse back onto her difficulties which precipitated her arrival” at the facility. Three months into her stay at the adolescent RTC, the patient’s initial diagnosis of Mood Disorder NOS had been changed to Major Depressive Disorder, Recurrent, Moderate due to her history of recurring major depressive episodes.

Upon receipt and review of the initial appeal letter, the insurance payer’s utilization review management department maintained denial stating that the patient did not meet certain Blue Cross behavioral health criteria for psychiatric residential treatment. Specifically, they stated that she was not showing behaviors which represented deterioration from her usual level of functioning 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 there was no evidence that treatment at this level of care would restore her previous level of functioning.

Subsequently, a timely second formal appeal letter was written and sent in late October, 2008. In this appeal, we attempted to document for the payer that the symptoms and behaviors the patient was experiencing met the requested level of residential care and that her services should be considered medically necessary and that they should authorize her care as such.

Additionally, we highlighted that outpatient individual and family therapy could not be considered as an alternative. In doing so, we pointed to the documentation we provided in the initial appeal which stated that the patient needed a more structured environment and a higher level of care based on her behaviors. Lastly, we enclosed copies of the patient’s current medical records for review by the insurance payer. However, upon receipt and consideration of the second appeal by the insurance payer’s utilization review management department, denial was upheld for the exact same reasons the first appeal was denied.

Final Outcome

Since the appeals process had been exhausted, 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 along with the request forms, 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 December, 2008, 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 this patient’s claims for the totality of her confinement in the adolescent RTC.

Claim Payment

The total charges for all services were $201,025.00. The insurance paid the claim at the contracted daily rate with the facility for a total of 100 days (per calendar year) which was the benefit maximum. The payment of her claims relating to the 2008 calendar year were paid at the contract rate of $37,700.00. Only 84 days were payable for the 2009 calendar year since the patient left the facility on March 25, 2009. Payment for those 84 days at the contract rate totaled $31,864.00.

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