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Patient Information

The patient was a 16-year old female with a diagnosis of Mood Disorder NOS, ADHD, Oppositional Defiance Disorder, Parent Child Relational Problems, and Poly-Substance Dependency.

Provider Information

Services were rendered to this patient at an adolescent residential treatment center located in Utah, from May 10, 2006 through June 17, 2007. The total charges for her treatment were $202,548.00. The family’s insurance, Aetna, denied payment for the patient’s entire stay, citing no medical necessity. Specifically, the insurance provider stated that this patient had made progress to an extent that there was an improved ability to function and to comply with treatment. They maintained that she did not require acute hospitalization. Instead, they stated that treatment could be provided at a lower level of care, or in another setting, such as partial hospitalization, or another type of outpatient setting.

History of Patient’s Condition

The patient’s psychiatric treatment history began in the 3^rd grade when she was diagnosed with ADHD. Although she was in the gifted program at school, she began having academic problems and worsening behavioral problems – including aggression and violence towards others - in her last year of junior high. In the 8^th grade, she threatened a student with a letter. And, in high school, she had a myriad of behavioral problems. In the ninth grade, she had two cases brought against her in court due to verbal threats and had two arrests for defacing school property. In 10^th grade, she was hospitalized for one week after becoming enraged and hitting her parents. She was also arrested twice in the eleventh grade – once for slapping a boy in school and another time for stealing a ring. Ultimately, she was placed in an alternative school and was never able to return to her original high school.

The patient had a history of self injurious behavior in the form of cutting herself as well as self piercing and tattooing. Additionally, the patient had a history of substance abuse and dependence that began when she started using alcohol in the 8^th grade. She started using marijuana at age 12 and huffing Dust-Off in the 9th and 10^th grades. She had also abused caffeine pills, Robitussin, and cigarettes. The patient reported a traumatic event that occurred when she was thirteen. She reportedly suffered physical and sexual abuse by a boyfriend who hit her and made her perform sexual acts that she did not agree to.

Through the years, she received treatment at all levels of care from intensive outpatient therapy to acute inpatient hospitalizations as well as treatment at all levels of care from intensive outpatient therapy to acute inpatient hospitalizations. She was also prescribed numerous medications such as Risperdal, Prozac, Trileptal Wellbutrin and Abilify. None of these treatment remedies were effective in alleviating and changing her behaviors.

Prior to being admitted to the adolescent residential treatment center in Utah, she was enrolled in a program for troubled teens in Idaho. She had been arrested and it had been a choice whether or not she went to the wilderness program or to jail. Just short of 60 days in the program, she attempted suicide by cutting her wrists and was able to contract for safety at the RTC in Utah. When the patient was admitted to the adolescent residential treatment center in Utah, the psychiatric evaluation documents stated that she had “worsening behavioral issues, relationship problems, people problems, drug problems, self-esteem issues, academic issues, mood problems and identity problems.” At the time of admission, she acknowledged using marijuana 3-4 times a week and snorting heroine 7-8 times a month. She had been lying and stealing from her parents and had generally been out of control. It was felt that this particular RTC was an appropriate placement for her.

Reason for Referral

The family’s insurance provider sent a letter on May 12, 2006, denying 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 the denial of the entire confinement for medical necessity. Such documents included all medical records from the adolescent residential treatment center in Utah, a copy of the plan booklet from Aetna, the clinical criteria used by the said claim payer to determine medical necessity, Aetna’ LOCAT assessment scoring forms, numerous 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 required continued acute hospitalization and that her treatment would not be sufficient at a lower level of care, or in another setting and that she meets residential level of care criteria.

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 was sent on September 1, 2006. It outlined the patient’s history of present illness and stressed the need for continued care in the adolescent residential treatment center in Utah. We targeted specific criteria from Aetna’s Level of Care Assessment Tool (LOCAT), which provides the guidelines for inpatient mental health residential level of care under Aetna’s Plan; and, we provided specific examples to uphold the claim that the level of care she was receiving was proportionate to her extensive needs.

We included several letters of medical necessity (LOMN) from various treating providers who recommended that she be admitted to the RTC in Utah because she needed to be in a highly structured environment in order to prevent a relapse to old self-destructive behaviors. Her individual therapist from 2003 through 2006 originally diagnosed her with ADHD and oppositional defiant disorder, but had been reviewing these diagnoses for possible bipolar disorder. He also noted the presence of borderline features. He continued to substantiate the need for her confinement in the residential treatment ceter (RTC) by pointing to her high-risk behaviors and self-destructive judgment and decision-making. He stated that her “functional level had spiraled downward very quickly” and noted his concern about discontinuation of treatment at the RTC as likely “placing her at serious risk.”

A letter from her family physician also substantiated the need for treatment at the level of care provided at the adolescent RTC in Utah. He confirmed that as witness to the patient’s long and complicated history with regard to her unpredictable, impulsive behavioral issues, she was continuing to spiral downward in terms of severity and risk. His concern was that the patient would be “prematurely transferred to a lesser intensive level of care before the goals of symptom resolution; healthier object relations; avoidance and replacement of substance using triggers with health coping strategies; are clearly mastered by her.”

We also included a letter from a psychiatrist at the adolescent RTC in Utah after completing the patient’s psychiatric testing. He determined that her problems were not the result of an acute behavioral or emotional episode – (which would indicate appropriateness for a lower level of care). Rather, he surmised that her clinical diagnoses in combination with her mood and emotional concerns clearly indicated her patterns of behavior had been escalating for the last few years.

Upon receipt and review of the initial appeal letter, the insurance payer’s utilization review management department sent a letter that maintained denial of payment, stating no medical necessity. Specifically, they pointed out that upon admission to the adolescent RTC, the patient was not depressed, did not have suicidal or homicidal ideation, and did not exhibit any psychotic thinking. Aetna’s LOCAT criteria supported intensive outpatient treatment as the medically necessary level of care.

Subsequently, a timely second formal appeal letter was written and was sent in late October, 2006. In this appeal, we restated the documentation of numerous clinicians and others who had conducted face-to-face examinations of the patient and determined that placement at the adolescent RTC in Utah was the recommended level of care for her. We noted that as a general rule, treating physicians’ opinions are not entitled to any greater weight than reviewing physicians in ERISA cases. However, with regard to psychiatric treatment in ERISA cases it has been determined that the opinions of treating physicians are inherently more creditable and reliable than the opinions of the reviewing physicians. Moreover, we emphasized that The American Psychiatric Association has stated that the primary assessment tool for a psychiatrist evaluating an individuals’ medical conditions and treating those conditions is the face-to-face interview with the patient and that, “evaluations based solely on a review of the records are inherently limited.” We urged Aetna to give this case additional consideration by completing another full, fair and thorough review of the denial of the patient’s claims at a second level internal review.

Final Outcome

In late November, Aetna held a Panel Review discussion on this patient. Nonetheless, the second appeal again resulted in the denial being upheld - for the same reasons the first appeal was denied. 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 review process. A letter and external review form signed by the family 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 January, 2007.

In late February 2007, after a full review of the appeals and medical records, the external review company, Maximus, overturned the decision rendered by Aetna. Ultimately, this reversal meant that benefit coverage for the totality of the patient’s care was approved.

Claim Payment

The total charges for all services were $202,548.00. The insurance paid the claim at their contracted daily rate with the facility for a total of $141,400.00.

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