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 services received Findings:  The physician reviewer found that the documentation does not indicate whether the patient had been in any type of substance abuse treatment prior to her admission to the program under dispute. The patient has depression and anxiety issues and appeared to make excellent progress in treatment. Progress notes for the period under dispute indicate the patient reported her mood as a 10 out of 10. Her family was engaged in therapy along with her. Progress notes indicated that she was engaging well with peers and reported a good mood. She was able to verbalize improvement in her relationships with family as well as with her target symptoms. The progress notes did not indicate that the patient was suffering from severe functional impairment or that she presented with serious functional impairment.  There were no indications that the patient was suicidal or homicidal or experiencing psychosis. In cases such as this, an evidence-based instrument such as the Child and Adolescent Level of Care Utilization System is indispensable in determining necessary level of care for children. In terms of risk of harm, the records support a score of 1. There was a lack of current self-harm ideation per the records. With regards to functional status, the records support a score of 1. In terms of comorbidity, the records support a score of 2. The patient does not have active serious medical problems or severe psychiatric symptoms. With regards to recovery environment level of care, the documentation supports a score of 2. The patient has had issues with family relationships, but has a stable housing situation. In terms of recovery environment level of support, the records support a score of 1. The patients family is actively involved in treatment and attended family therapy sessions on a regular basis. With regards to resiliency and treatment history, the records support a score of 3. There is no apparent recent treatment and unclear success with past treatment. In terms of acceptance and engagement of the patient, the records support a score of 2. The patient actively participated in therapy. With regards to acceptance and engagement of the parent, the records support a score of 2. The parents worked actively and constructively with clinicians. Thus, the patient has a composite score of 14. A score of 14 correlates with outpatient services. Cognitive behavioral therapy is a mainstay for anxiety treatment and is effective on an outpatient basis. All told, services received from the provider were not medically necessary for the 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 with sub-specialty certification 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.