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

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for six additional weeks for wraparound services. The Child and Adolescent Level of Care Utilization System (CALOCUS) provides a framework for determining the clinically appropriate level of care for a child or adolescent in mental health treatment. With regard to risk of harm, the records support a score of 2. The patient has some risk of harm, due to suicidal statements when angered and a history of uncontrolled anger and aggression towards his parents. The records do not note a history of suicidal ideation or self-harm, or engagement in risky behaviors, including aggressive behaviors during recent participation in WRAP. In terms of functional status, the records support a score of 3. The documentation noted moderate functional impairment as the patient has made gains in his functioning while in treatment, meeting his treatment goals and is ready to be stepped down to a lower level of care. However, he also has a history of academic failure, severe deficits in interpersonal relationships with his parents, and aggression towards his parents. With regard to comorbidity, the records support a score of 2. The patient had minor comorbidity, due to a medical history of congenital hypothyroidism, a condition that can cause or exacerbate symptoms of depression, including irritability. In terms of level of stress of the recovery environment, the records support a score of 3. The patient had a moderately stressful environment as the records note that the patient has been aggressive towards his parents, resulting in the police being called to the home, and defiant. The records also indicate problems at school necessitating the services of a tutor. With regard to level of support of the recovery environment, the records support a score of 3 due to his parents support and engagement in treatment. However, there appears to be disagreement between the parents about how to best address the patients problematic behaviors and parenting inconsistencies. In terms of resiliency and treatment history, the records support a score of 3. The patient had moderate or equivocal response to treatment, as he has met goals established with wraparound services and is ready to step down to lower level of care. With regard to treatment acceptance and engagement, the records support a score of 3. The patient appears to struggle to connect to treatment providers, although he is compliant with medications. Thus, the patient has a total score of 19. In this case, the recommended level of care is high intensity community-based services. In this patients case, six additional weeks for wraparound services are not accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the requested services are not clinically appropriate in terms of type, frequency, extent, site, and duration. The requested services are primarily for the economic benefit of the health care service plan and subscribers or for the convenience of the patient, treating physician, or other health care provider. Therefore, six additional weeks for wraparound services are not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested services are 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 sub-specialty certification 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.