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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment center (RTC) provided for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that 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. The patient met the following criteria on 11/3/16: Using this criteria, the patients risk of harm is scored a 3, which is associated with a moderate risk of harm. The patient was hospitalized in June 2016 due to emotional lability, self harming urges, suicidal ideation, and explosiveness. There was no documentation that the patient had any suicidal ideation, self harming incidents, or explosive behavior during their stay at RTC. The patients functional status is scored a 3, moderate functional impairment. The patient has a very conflicted and troubled relationship with their mother. Per the submitted documentation, the patients behavior worsens around the patients mother. The patients co-morbidities is scored a 3, which correlates to significant co-morbidities. The patients co-morbidities include dysthymia, unspecified anxiety disorder, and ADHD. The patient did not have any medical conditions that would require 24 hour monitoring. In the area of recovery environment, the patients environmental stress is scored a 3, moderate stressful environment. The patient has frequent conflicts with their mother, which cause distress. The patients environmental support is scored a 3, limited support in the environment. The patients mother is supportive, but it appears that the patients mother has caregiver fatigue. The patients resiliency is scored a 2, which is associated with positive response to treatment.  The patient was treated in an inpatient psychiatric unit in June 2016 and then was treated in a wilderness program. Documentation did not report any suicidal ideation, self harming behaviors, aggressiveness, or explosiveness. It appears that the patients previous treatment was beneficial to the patient, which improved behavior and impulsivity. The patients acceptance and engagement is scored a 2, constructive. The patient was able to develop positive relationships with clinicians and participate in treatment.  According to the CALOCUS criteria, the patients composite score is 19, which correlates to treatment at an intensive outpatient program (IOP). The patient continued to need treatment for dysthymia, unspecified anxiety disorder, and ADHD. However, the patients treatment could have been performed at a less restrictive environment. Therefore, RTC services were not medically necessary for treatment of her medical condition. 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.