Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment center services for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that in order to objectively determine the appropriate level of care for this patient, the Child and Adolescent Level of Care Utilization System (CALOCUS) was utilized. This is an accepted, national standard for determining the appropriate level of care for children and adolescents. The patient met the following criteria: The patients risk of harm is scored a 3, which correlates with significant risk of harm. The patient has a history of self cutting. The patient had several suicidal behaviors of overtaking medications, which in the documentation has been described as an overdose. However, none of these overdoses required the patient to go to the emergency department to be evaluated. The patient does engage in self cutting behaviors on occasion. The patients functional status is scored a 3, moderate functional impairment. The patient refused to go to school prior to being admitted. However, the records noted that while at the residential treatment center, the patient was participating in school and engaging in activities and therapy sessions. The patients records document that the patient has borderline intellectual functionality, so the patient has chronic deficits in interpersonal relationships. The patients co-morbidity is also scored a 3, which correlates to significant co-morbidity. The patient has a co-morbidity of borderline intellectual functioning, ADHD, and depression. The patient has no substance problems. The patient is medically healthy and does not require 24 hour medical monitoring. Her recovery environment, which measures the patients environmental stress, environmental supports, resiliency and acceptance are as follows: The patients environmental stress is scored a 3, moderately stressful environment.  The patients stresses at home come from not meeting the patients parents expectations and parental conflicts over her relationships with the opposite gender, inappropriate social media usage, and school performance.  The patients environmental support is a 2 which is correlates to a supportive environment.  The patients parents are supportive of the patient.  Her resiliency is scored a 2, positive response to treatment. It appears from the records that prior treatments have helped the patient. She is appropriate with staff. The patient does not have any suicidal ideation. The patients psychiatrist noted that the patients mood was good and that the patient had a bright affect. There were no changes to the patients medications at the time.  The patients acceptance and engagement is scored a 2, which is constructive. The patient would participate in activities and therapy sessions.  Based on CALOCUS, the patient had a total score of 18 and met criteria for an intensive outpatient program (IOP) and not residential treatment services. The standard of care is to treat the patient in the least restrictive environment as possible. The patient continued to need treatment for the patients depression, neurodevelopmental disorder, and ADHD, but this could have been provided in a less restrictive environment. Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in psychiatry with expertise in child and adolescent psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.