2009 DMH Eligibility Decision by Hearing Officer Luberoff - 5

Outcome: Ineligible

Keywords: functional impairments, PTSD, remission

Hearing Officer: Luberoff

Counsel present for Appellant: Yes – Bryant Cortes

Counsel present for DMH: Yes – Kathleen Callahan

Appellant present: No

Hearing Officer decision: 2009

Commissioner letter: N/A

The appellant, now 18, was removed from her home and placed in a residential school at the age of 13, after suffering neglect and abuse (particularly sexual abuse) and having had six psychiatric hospitalizations.  She has been diagnosed with Learning Disorder, Attention Deficit Hyperactivity Disorder (ADHD) and Post Traumatic Stress Disorder.  Her problems have included oppositional aggressive and sexual behaviors, hallucinations, poor self-care skills, and suicidal and homicidal ideation.  Her PTSD is thought to be responsible for the hallucinations, as well as persistent bad dreams and a fear of men.  IQ tests have shown her to be of at best borderline intelligence, but doctors have speculated that her actual IQ is probably higher.

Since attending the residential school, the appellant’s behavior and wellbeing has markedly improved, thanks to a combination of a structured environment and medications.  She has not reported having hallucinations in the past two years.  However, she continues to have bad dreams about her traumatic experiences and suffer from emotional instability.  Staff at the school believe that she does not have the life skills necessary to live independently, and that she would not continue to take her medications if unsupervised.

The appellant’s application for DMH services had been denied several times, including in 2007 when the Area Medical Director concluded that her impairments are not primarily due to a qualifying disorder.  The Area Medical Director’s decision was upheld twice.  A clinician at the appellant’s school appealed again. The appellant submitted a medication history, which shows few medication changes over the past few years and a significant decrease of problematic behaviors. 

The appellant was evaluated by Dr. Rausch, who testified for the DMH, saying that the diagnosis of PTSD was inaccurate, and that that some of the symptoms she has that resemble those of PTSD could also be attributed to cognitive limitations, failure to learn coping skills and ADHD.  According to Dr. Rausch, a number of her problematic behaviors are not associated with PTSD.  He also stated that, if she has PTSD, it is in remission.

The hearing officer came to the conclusion that the DMH was unreasonable in determining that the appellant did not have PTSD, which is a qualifying mental illness.  The hearing officer also found that she had significant functional limitations.  However, the hearing officer did not find that these impairments were due to PTSD, as she continued to need constant supervision to keep her safe and could not function independently even while her PTSD was in remission.  As a result, the hearing officer held that the appellant was unable to prove that the DMH was unreasonable in denying her services, and thus she is ineligible to receive them.