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Patient Information

The patient was a 17-year old male with a diagnosis of major depressive disorder, moderate, recurrent, poly-substance dependence in partial remission in a controlled environment, and parent/child relational problem.

Provider Information

Services were rendered to this patient at an adolescent residential treatment center located in Utah, from April 30, 2007 through February 15, 2008. The total charges for his treatment were $151,851.00. The family’s insurance, Anthem Blue Cross, denied payment for the patient’s entire stay, citing no medical necessity. The insurance provider maintained that review of the information provided indicated that the patient was not taking unnecessary risks or doing potentially lethal things that required medical intervention and containment in a 24-hour sub-­acute treatment setting. Additionally, they stated that there was no evidence that treatment at this level of care would restore the patient’s previous level of functioning, or that the patient was willing and/or able to benefit from this level of care.

History of Patient’s Condition

The patient’s psychiatric treatment history included many different programs. He received individual and family therapy on an outpatient basis as needed from 3^rd – 9^th grade. In terms of inpatient treatment, he was at Coran RTC for drug abuse and addiction, Reading Hospital, Interim Care at Philhaven, and The Meninger Clinic. After a 3-week assessment at The Meninger Clinic, it was recommended that the patient receive continued treatment in an Adolescent Treatment program. The patient’s drug and alcohol history began at age 15 and included the use of marijuana (two to five times per day) and DXM daily. He had tried alcohol, crack and cocaine, and smoked one-half pack of cigarettes per day. Throughout his treatment, the patient had been treated with medication including Zoloft, Abilify, Welbutrin and Sertraline.

When the patient was admitted to the adolescent residential treatment facility in Utah, he was exhibiting worsening behavioral problems, anxiety, oppositional –defiant behavior, major depressive disorder, recurrent, severe, significant chemical dependency issues including daily DXM and Cannabis abuse, a history of failed treatment at lower levels of care, and a history of relapses. The patient also had sleep disturbance, social isolation, low energy, fatigue, poor concentration and self injurious behavior.

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 no medical necessity.

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 Anthem Blue Cross, the clinical criteria used by the said claim payer to determine medical necessity, letters of medical necessity from prior treating providers and inpatient facilities, and various reports and testing documentation.

Barriers to Overcome

We needed to convince the claim payer 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 treatment at this level of care would restore the patient’s previous level of functioning and that the patient was willing and able to benefit from this level of care.

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 the need for continued care in this adolescent residential treatment center. In doing so, we highlighted notes from the patient’s Initial Treatment Plan at the residential treatment center in Utah, which clearly stated the need for continued treatment in this facility. It specifically stated that the patient had a history of self harm, depression, struggles with school, getting along with peers, parent-child relationship problems, and self esteem issues, substance abuse and suicidal ideation. He was having increased trouble getting along with his parents. He had expressed some suicidal ideation with one quasi-suicide attempt and he struggled with injuring himself through cutting behaviors. Additionally, we pointed to the patient’s initial psychiatric evaluation in which the psychiatrist’s clinical impression was that the patient’s placement at the RTC was an appropriate one considering his long history of depression, substance abuse, relationship issues, and behavioral problems.

Upon receipt and review of the initial appeal letter, the insurance payer maintained denial stating that there was no reasonable expectation that the member’s illness, condition, or level of functioning would be stabilized and improved through an intensive, short-term residential program. They also maintained that the patient did not undergo individual sessions with a psychiatrist on at least a weekly basis, as required by the Plan.

Subsequently, a timely second formal appeal letter was written and sent upon the patient’s discharge from the RTC. In this appeal, we included medical records from physicians and psychiatrists at the RTC the patient could be successful in the program and was indeed benefiting. We maintained that he was progressing through the levels and was controlling his emotions much better than at admission. The medical notes indicated that the patient was learning new skills to regulate his mood. He was exhibiting less depression with affect that was moderately brighter than in the past, a positive attitude, and good insight and judgment. Finally, we included progress notes from the physician/nursing staff which showed that the patient was seen on a regular basis by a psychiatrist.

This second appeal was also upheld by the insurance payer stating that the documentation provided did not support that the medical necessity criteria had been met for inpatient residential level of care. Therefore, it was decided to send a request to the State of Connecticut (which is where the patient resided) for consideration of a voluntary external appeal process. A letter was sent to the state of Connecticut within 60 days (each State has a different timely filing period) of the denial date on the second denial letter. Maximus, The Center for Health Dispute Resolution, accepted the case for full review in early June of 2008 – nearly four months after the patient’s discharge from the residential treatment center.

Final Outcome

In July 2008, after a full review of the appeals and medical records etc., the external review company, Maximus fully reversed the decision rendered by Anthem Blue Cross. Ultimately, this reversal meant that the patient’s claims would now be paid by the claim payer, per the provisions of the Plan.

Claim Payment

Once the State of Connecticut external review program, through the external review vendor, Maximus overturned the Anthem Blue Cross denial in June of 2008, we had to maintain diligent communication through continual phone contact with the insurance payer in order to get all the reversed claims paid. The first payment was received in August 2008 and the final payment was received 8 months later, in April 2009.

The total charges for all services were $151,851.00. The insurance paid the claim at the contracted daily rate with the facility for a total of $110,084.00. The family was paid back all monies they paid minus their co-payments and deductibles.

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