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. Findings:  The physician reviewer found that in order to objectively determine the appropriate level of care for the patient, the Child and Adolescent Level of Care Utilization System (CALOCUS) was utilized. This is an accepted, national standard for determining the appropriate level of care for children and adolescents. The patient met the following criteria:With regards to risk of harm, the patient is scored a 2, which correlates to mild risk of harm. The patient does not have a history of suicide attempts. The patient has a history of suicidal thoughts when the patient was in the seventh grade in which the patient was hospitalized for one week. The patient did not endorse any thoughts of suicide. The patients functional status is a 3, which correlates to moderate functional impairment. The patient has conflicted relationships with the patient peers. The patient tends to argue with the patients peers and has occasionally got into physical altercations with the patients peers, which has led the patient to several suspensions at school. The patient has chronic severe deficits in his interpersonal relationships and his ability to engage in socially constructive activities. While in the RTC, the patient has had verbal altercations with peers and staff, but the patient did not have physical altercations. The patient has a score of 3 with regards to comorbidity. The patient has a comorbidity of depressive disorder, ADHD, oppositional defiant disorder (ODD), and neurodevelopmental disorder. The patient does not have any medical problems which require 24 hour monitoring. The patients recovery environment includes a score of 3. The patient finds social milieu to be stressful and has difficulty making and keeping social relationships. The patient also has expectations for performance at school and family life, which create discomfort if not met. The patients environmental support is scored a 2 which correlates to supportive environment.  The patients parents are supportive of the patient.  The patients resiliency is scored a 3. The patient has had prior treatment through medication management and wilderness therapy. The patient continues to have ADHD symptoms and oppositional behaviors.  The patients acceptance and engagement is scored a 3, obstructive. The patient has difficulty forming positive relationships with clinicians and care providers. At times, the patient will have difficulty following instructions. According to the CALOCUS criteria, the patients total composite score is 19. Based on these criteria, the patient would meet criteria for an intensive outpatient program (IOP) and can be treated in a less restrictive environment. The patient continues to require treatment for the patients depressive disorder, ADHD, ODD, and neurodevelopmental disorder. However, this could have been provided in a less restrictive environment. Therefore, RTC services from were not and are not medically necessary. Final Result: The reviewer determined that the services at issue were 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.