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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for residential treatment center services.  The Health Plan has denied this request indicating that the services at issue were not and are not medically necessary for treatment of the enrollees behavioral health condition.Findings: 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. Review of the submitted medical records reveals that by 9/4/17 and 9/5/17, the patient met the following criteria: With regards to risk of harm, the records support a score of 2, mild risk of harm. The patient does not have a history of suicide attempts or self injury. On the dates in question, the patient did not have any suicidal or homicidal ideation.  Her functional status is scored a 3, moderate functional impairment. The patient had been refusing to go to school. However, on 9/4/17 and 9/5/17, the documentation noted the patient was eager to start working on school work and kept boundaries and respected staff and was in a good mood and handled disagreements with peers in a mature way and was getting along great with the other girls. The patient appeared to be taking care of her activities of daily living. She was engaged in treatment and was participating in treatment.  Her co-morbidity is scored a 3, which correlates to significant co-morbidity. The patient has co-morbidities of generalized anxiety disorder, gender identity disorder, and oppositional defiant disorder. However, the patient did not have any medical problems, which would require 24 hour supervision. The patients environmental stress is scored a 3, moderately stressful environment. The patient has interpersonal conflicts with her parents, which causes stress in the home. The patient previously had been refusing to participate in family therapy. Her environmental support is a 2, supportive environment. The patients parents are supportive of the patient. The patients resiliency is scored a 3, equivocal response to treatment. Prior treatment in PHP and IOP were self-discontinued by the patient which led to an equivocal response to prior treatment. The patients acceptance and engagement is scored a 2, constructive. The patient was participating in treatment and was getting along with peers and staff.Based on the CALOCUS criteria, the patients total composite score is 18. The patient would meet criteria for IOP and could have been treated in a less restrictive environment. The patient continued to need treatment for major depressive disorder, generalized anxiety disorder, gender identity disorder, and oppositional defiant disorder. However, by 9/5/17 the patient could have been treated at a less restrictive environment. The records did not support 24 hour care.  As such, the medical necessity for residential treatment center services provided from 9/5/17 forward has not been established for treatment of this patient. Final Result: The reviewer determined services at issue were not and 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 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.