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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the acute psychiatric services for treatment of the enrollees behavioral health issues. Findings:  The physician reviewer found that To objectively determine the appropriate level of care for the patient, the case was examined using the Child and Adolescent Level of Care Utilization System (CALOCUS). This is an accepted, national standard for determining the appropriate level of care for children and adolescents. The records indicate that on 9/20/17, the patient did not meet the CALOCUS criteria for treatment with acute psychiatric services. The patient was at low risk of harm (score 2) as he does not have a history of suicide attempts and did not have any suicidal ideation or homicidal ideation when he was admitted to the acute inpatient psychiatric center. The patient demonstrated moderate functional impairment (score 3) as he had been struggling with school due to his inability to focus and due to his recent psychotic episode. However, the patient had improved with treatment. He was less anxious, interacted with the staff appropriately, was participating in groups, and did not have any auditory or visual hallucinations or paranoia. The patient was future oriented about returning to school and resuming his studies. The patient demonstrated significant comorbidity (score 3) with a recent psychotic episode that was possibly due to schizophrenia. The patient was also abusing cannabis but was otherwise medically healthy and did not require 24-hour medical monitoring. The patient is noted to have a mildly stressful recovery environment (score 2) as he did have stress due to starting a new school, living away from family, and expectations for school performance. The patients environmental support was positive (score 2) as the patients parents were supportive of the patient. The patient had demonstrated significant resiliency and response to treatment (score 2) and was previously hospitalized for a psychotic episode. It appears that this episode resolved after the patient was started on risperidone. The patient stopped this medication which led to a relapse in his psychotic symptoms. Overall, the patient has been constructive in treatment (score 2) as he was described as cooperative with staff and participating in groups. He was eating 100% of his meals, was visible on the unit, and did not have any manic symptoms. The patient remained guarded, but the providers notes state that he communicated well with the staff. This gives the patient a composite score of 16 which is consistent with routine outpatient treatment. By 9/20/17, the patient had improved enough to be treated in a less restrictive environment as an outpatient. Therefore, the acute psychiatric services provided were not medically necessary for treatment of this patients behavioral health issues. 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.