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 mental health substance abuse level of care services for treatment of the enrollees behavioral health conditions. Findings:  The physician reviewer found that in order to objectively determine the appropriate level of care for the patient, the Child and Adolescent Level of Care Utilization System (CALOCUS) was utilized. This is an accepted, national standard for determining the appropriate level of care for children and adolescents. The patient met the following criteria. In terms of risk of harm, the records support a score of 3. The patient has a history of excessively using substances. The patient accidentally overdosed on Benadryl and cough syrup. The patient did not have any suicidal or homicidal ideation. With regards to functional status, the records support a score of 3. The patient had moderate functional impairment. His behavior had deteriorated due to his substance use. He improved with treatment, but continued to have symptoms of irritability, depression, sadness, and anxiety. In terms of comorbidity, the records support a score of 3. The patient had comorbidities of major depressive disorder, generalized anxiety disorder, attention deficit/hyperactivity disorder, cannabis use disorder, opioid use disorder, sedative/hypnotic anxiolytic use disorder, and stimulant use disorder. The patient did not have any medical problems which required 24-hour monitoring. With regards to environment stress, the records support a score of 3. The patient had a moderately stressful environment. He had interpersonal conflicts with his family due to his impulsivity and substance use. His girlfriend also recently broke up with him. In terms of environmental support, the records support a score of 2. The patients parents are supportive of the patient. With regards to resiliency, the records support a score of 2. The patient has had improvement with treatment. In terms of acceptance and engagement, the records support a score of 2. The patient was cooperative with treatment. He was motivated for sobriety. Based on the above, the patient has a composite score of 18. Thus, the patient met criteria for an intensive outpatient program and could have been treated in a less restrictive environment. The patient continued to need treatment for his major depressive disorder, generalized anxiety disorder, attention deficit/hyperactivity disorder, cannabis use disorder, opioid use disorder, sedative/hypnotic anxiolytic use disorder, and stimulant use disorder, but this could have been done in a less restrictive environment. 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.