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

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement for residential treatment center services. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue. The Child and Adolescent Level of Care Utilization System (CALOCUS) is an accepted, national standard for determining the appropriate level of care for children and adolescents. In terms of risk of harm, the records support a score of 3. The patient had a history of prior suicide attempt and self-injury. With regards to functional status, the records support a score of 3. The patient had moderate functional impairment. The records documented chronic deficits in her interpersonal relationships and her ability to maintain responsibilities. She had chronic deficits in her ability to engage in socially constructive activities. In terms of comorbidity, the records support a score of 3. The patient had comorbidities of mood disorder, obsessive-compulsive disorder, posttraumatic stress disorder, and borderline traits. She did not have any serious medical problems which required 24-hour monitoring. The patient had experimented with substance use, but did not engage in heavy substance use. With regards to environment stress, the records support a score of 3. The patient had a moderately stressful environment. She had interpersonal conflicts with her parents due to having episodes of agitation and impulsivity. In terms of environmental support, the records support a score of 3. The patient had limited support. Per the records, she has supportive parents who are willing to participate in treatment. However, it appears that the parents have caregiver burn out. In terms of previous response to treatment, the records support a score of 3. The patient has had prior residential treatment which has not resolved her symptoms. She demonstrated an equivocal capacity to deal with stressors. With regards to acceptance and engagement, the records support a score of 3. The patient minimized her problems and did not take responsibility for her contribution to the problem. She was typically ambivalent with her relationship with the providers.  The patient typically participated in activities and therapy and passively cooperated in treatment planning and treatment. Therefore, the patient has a composite score of 21. Based on these criteria, the patient met criteria for a partial hospitalization program. The patient could have been treated in a less restrictive environment. She had made improvements in her residential treatment. The patient continued to need treatment for her mood disorder, obsessive-compulsive disorder, posttraumatic stress disorder, and borderline traits, but this could have been accomplished is a less restrictive environment. Therefore, residential treatment center services provided from were not medically necessary for the treatment of this patient. 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.