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

Nature of Statutory Criteria/Case Summary: The parent of a patient has requested reimbursement for the residential treatment center services in the wilderness setting from 4/10/17 through 7/11/17. The Health Plan has denied this request indicating that the services at issue were not medically necessary for treatment of the patients behavioral health condition. The submitted documentation does not support the medical necessity of the services at issue. On 4/10/17, the patient presented to the wilderness program with a history of oppositional defiant disorder, parent child relational problem, sibling relational problem, and cannabis use disorder. The records noted that during treatment, the patient was cooperative, calm, and insightful into this patients psychological needs. The progress notes did not indicate that the patient had psychosis, paranoia or mania symptoms. The records did not indicate other severe psychiatric symptoms that would require intensive psychiatric care. The American Academy of Child and Adolescent Psychiatry has indicated that residential treatment should include a child and adolescent psychiatrist, or in the case of an adolescent program, an adult psychiatrist with training and certification in treating the child and adolescent age group. Current guidelines state that the psychiatrist should meet with the patient weekly or more as clinically indicated. This wilderness program at issue does not appear to meet that criterion, as there was no evidence of weekly psychiatric visits with this patient. The reference further indicates that residential treatment is appropriate when the treating clinician has considered less restrictive resources and determined that they are either unavailable or not appropriate for the patients needs. Based on the records submitted for review, it is not clear that less restrictive resources were not available or appropriate for the patients needs. The documentation does not support failure of outpatient therapy, intensive outpatient therapy, partial hospital program therapy, or cognitive behavioral therapy. The progress notes indicated that the patient had parent child relational, and sibling relational problems and that the patient participated in a form of family activities during treatment. However, it is not clear if the family was engaged in family therapy in an outpatient setting. Functional family therapy would have been appropriate and indicated, as it has proved highly successful in decreasing violence, drug abuse/use, conduct disorder, family conflict and reducing residential treatment placements and juvenile involvement with correctional systems. In this case, functional family therapy, which is typically administered in an outpatient setting, would have been appropriate for this patient and the patients family members. The American Academy of Child and Adolescent Psychiatrys practice parameter regarding the treatment of oppositional defiant disorder states that intensive in-home therapies such as, multi-systemic therapy, wraparound services, and family preservation models are preferable alternatives to residential placement. Outpatient youth were more likely in the future to live with family, make progress in school, have lower recidivism rates with the law, and have better placement permanence than youth in residential treatment. The record did not indicate that the patient had active suicidal ideation, substance withdrawal, or substance intoxication symptoms. It appears that the family was engaged in the patients treatment. Evidence based childrens mental health treatment has shown that treatment outside of a residential setting is effective, appropriate and is as beneficial as residential treatment programs. This patient did not demonstrate severe symptoms or dangerous behaviors and less restrictive treatments would have been appropriate. Due to the lack of evidence to support failure of less restrictive treatments and the patients overall mild symptoms, treatment in a residential setting was not medically necessary. In summary, the residential treatment center services in the wilderness setting from 4/10/17 through 7/11/17 were not medically necessary for 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 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.