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 long-term residential dual-diagnosis treatment center 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 3. The patient had a significant risk of harm, due to a history of alcohol and substance use resulting in potentially harmful behaviors. Notes dated reported a suicide attempt by overdose. She was not noted to have active suicidal ideation or intent, means, or plans but the records noted that she was at high risk of another suicide attempt. The patient was noted to be participatory and compliant in PHP, without safety concerns or reports of substance use relapse.In terms of functional status, the records support a score of 3. The documentation noted moderate functional impairment due to some improvements in function. She was able to engage in socially constructive activities and maintain responsibilities. In notes, the patients father reported that the patient had torn about her room looking for substances that she had previously hidden, and that during a trip to the aquarium the previous week, the patient was anxious and afraid of crowds and froze in place. The patients parents reported concerns that the patient would be overwhelmed with transitioning to school and that she would access substances through peers. The records noted symptoms of anxiety and depression, occasional panic attacks, paranoia and persecutory delusions. With regard to comorbidity, the records support a score of 3. The patient had significant comorbidity, due to the presence of alcohol and substance use along with symptoms of anxiety and depression. The records noted a recent hospitalization following a suicide attempt by overdose. 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 her home environment appears contentious and difficult, with significant parent-child conflicts. With regard to level of support of the recovery environment, the records support a score of 3 due to the parents limited ability to respond appropriately to the patient's developmental needs.In terms of resiliency and treatment history, the records support a score of 2. The patient shows significant resiliency and/or response to treatment as she appears to have benefited from treatment and improved clinically. With regard to treatment acceptance and engagement, the records support a score of 4. The patients parents were noted to have poor compliance and not agree with the patients treatment plan.Thus, the patient has a total score of 21. In this case, the recommended level of care is medically monitored nonresidential services. In this patients case, RTC level of care is not in 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, long-term residential dual-diagnosis treatment center 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.