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

Nature of Statutory Criteria/ Case Summary:  The enrollees parent is requesting reimbursement for residential behavioral health level of care. The enrollee has oppositional defiant disorder (ODD), unspecified trauma, stressor-related disorder, and cannabis use. The enrollee was in a wilderness therapeutic program. His parent is concerned about his oppositional behaviors, not following the rules, lying, stealing, smoking marijuana, and poor school performance. Admission assessment noted no signs of depression, anxiety, self-harm, or suicidal ideation (SI). He struggled with reading cues, becoming defensive, and lashing out at others when he felt threatened or ridiculed and refused to perform scholastic work. He made friends and integrated into the milieu. The enrollee was discharged with the same admitting diagnoses and with recommendations for therapy. Review of the record does not indicate the enrollees being prescribed psychotropic medications, or having suicidal ideations or psychiatric hospitalizations. While at the residential treatment center (RTC) program he was participating in individual, group and family therapy. The enrollee usually maintained a positive attitude, even when he did not wish to share his feelings or thoughts. The Child and Adolescent Level of Care Utilization System (CALOCUS) is a level of care assessment tool used by behavioral health managers and clinicians to support accurate level of care recommendations and was applied in this review. For risk of harm, the enrollees score is 2, due to an indication or report of occasional impulsivity and/or some physically or sexually aggressive impulses with minimal consequences for self or others. There is substance use without significant endangerment to self or others. For functional status, the enrollees score is 3, due to the enrollee being conflicted, withdrawn, or otherwise troubled in relationships with peers, adults, and/or family, but without episodes of physical aggression. School behavior has deteriorated to the point of the child/adolescent having to face some school disciplinary action and is at risk for placement in an alternative school program. For comorbidity, the enrollees score is 2, due to occasional, self-limited episodes of substance use present that show no pattern of escalation, with no indication of adverse effect on functioning or the presenting condition. For recovery environment level of stress, the enrollees score is 2, due to expectations for performance at home or school that create discomfort. The potential for exposure to substance use exists. For recovery environment level of support, the enrollees score is 1, due to continuity of active, engaged primary caretakers, with a warm, caring relationship with at least one primary caretaker. For treatment and recovery history, the enrollees score is 3, due to recovery being maintained for moderate periods of time, but only with strong professional or peer supports or in structured settings. For engagement and recovery of the adolescent, the enrollees score is 3, due to the enrollee acknowledging existence of the problem, but resisting acceptance of even limited age-appropriate responsibility for development, perpetuation, or consequences of the problem. He minimizes or rationalizes distressing behaviors and consequences.  For acceptance and engagement of the parent, the score is 2, due to the parents developing a positive therapeutic relationship with clinicians and other primary caretakers. The parent explores the problem and accepts others definition of the problem.  The parent works collaboratively with clinicians and other primary caretakers in development of treatment plan. The enrollees CALOCUS score is 18; however, having a score of 3 on Dimensions II and V requires a recommendation of Level III, intensive outpatient services. The medical evidence does not support the services at issue in this clinical setting. Final Result: The reviewer determined that the requested services were not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in psychiatry and 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 similar medical condition.