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

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) services. For dimension 1, the patient has been at significant risk of harm (score 3) due to chronic passive suicidal ideation and a history of cutting. The provider noted that the patient has threatened to hurt herself with a knife. The patient displays chronic poor impulse control, reactivity, and difficult family dynamics as well as history of severe substance abuse. The patient reportedly has a previous history of suicidal gesture. By the date of denial, the patient did not express acute concerns for suicidal, self-injurious, aggressive, or psychotic tendencies. The records document no active suicidal or homicidal ideation, but extreme distress and a history of suicidal behavior. For dimension 2, the patient has demonstrated mild functional impairment (score 3) with a history of substance use that has impeded on her functioning including relationships, safety concerns, and school functioning. The patient reported that she is motivated to stop using substances. However, the patients history suggests significant challenges with substance use given severity of her use.  Prior to entering RTC, the patient was intoxicated at a family gathering, and she was using during an overnight visit with a friend. By the date of denial, the patient reported motivation to abstain from substance use and she was cooperative with fair treatment insight. The patient demonstrates significant improvement in function following a period of deterioration. For dimension 3, the patient has significant comorbidities (score 3) with a diagnoses of ADHD, bipolar affective disorder, and severe substance use with significant adverse effect on functioning and her presenting condition. The patients symptoms have recently been ameliorated due to the protected setting of RTC. Recent substance use that has significant impact on the presenting condition has been arrested due to use of a highly structured or protected setting or through other external means. For dimension 4A, the patients recovery environment is highly stressful (score 4). The records document that the patients parents are divorced and there is concern that her parents have given her cannabis and alcohol, pointing to poor boundaries and limited ability for parents to institute structure. The patient has a history of pushing and hitting her mother when her mother attempts to institute limits. Historically, the patient has experienced challenges with obtaining substances while in the community. This supports serious disruption of family and social milieu. For dimension 4B, the patients recovery environment provides limited support (score 3) as her parents have demonstrated efforts towards effecting needed changes. However, the patients mother also appears to have a relationship with the patient that limits the mothers ability to maintain boundaries. Family or primary caretakers demonstrate only partial ability to make necessary changes during treatment. For dimension 5, the patient has exhibited moderate or equivocal resiliency and response to treatment (score 3). Despite previous intensive outpatient program (IOP), RTC, and psychiatric hospitalization, the patient still has shown difficulties ameliorating her mental health concerns. The patient has demonstrated an inconsistent or equivocal capacity to deal with stressors and maintain normal development. For dimension 6, the patient has been constructive in treatment (score 2) due to reports from providers that she has been motivated to stop using substances and has participated in therapies. The patient has been able to develop a trusting, positive relationship with clinicians and other care providers. These findings give the patient a composite score of 21, which is consistent with medically monitored community-based services. By the date of denial, the patient was stabilized sufficiently to meet the criteria for treatment in a less restrictive level of care. Moreover, the RTC services are not clinically appropriate in terms of type, frequency, extent, site, and duration. Therefore, the RTC services were not and are not medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were not and 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 subspecialty 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.