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 residential treatment center services. The submitted documentation fails to demonstrate the medical necessity of the services at issue. The patient was admitted over three weeks prior to the date of Health Plans denial. During the stay, the patient was noted to be cooperative in treatment. The patient was engaged in family and individual therapy and was noted to have significant improvement in her anxiety. As the stay progressed, the patient gained more insight into the diagnosed anxiety. The records indicate that the pateint made significant progress. Per the records, the patients symptoms stabilized, and the patient no longer needed residential treatment during the dates of service in dispute. The progress notes do not indicate that the patient made any suicide attempts or self-harm attempts during the stay. There was no notation that the patient had extreme mood swings, psychosis or other severe psychiatric symptoms. The patient was receiving psychotherapy at the residential treatment center and could have received dialectical behavioral therapy (DBT) on an outpatient basis. This type of therapy has been proven to be beneficial in reducing mood symptoms, emotional dysregulation and suicidal behavior in adolescents. DBT is routinely provided on an outpatient basis.The American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) is a utilization system used to assess level of care needs for children and adolescents receiving psychiatric care. With regards to risk of harm, the records support a score of 2. The patient was not actively suicidal during the disputed dates of service. The patient was not engaging in self-harm behaviors or expressing suicidal ideation, although the patient did have a remote history of this. In terms of functional status, the records support a score of 2. The patient has had some issues with level of function, but the progress notes indicate significant improvement after a period of deterioration. With regards to comorbidity, the records support a score of 2. The patient did not have active medical problems, and the records noted mild cannabis use issues. In terms of level of stress of the recovery environment, the records support a score of 2. The patient was noted to have interpersonal conflict with family members. With regards to level of support of the recovery environment, the records support a score of 2. The patients parents were involved in treatment. In terms of resiliency and treatment history, the records support a score of 3. The patient had a good response to a short period in the residential treatment center prior to the disputed dates. With regards to acceptance and engagement of the patient, the records support a score of 2. The patient participated in therapy actively, and insight and judgment were noted to be good throughout treatment. In terms of acceptance and engagement of the parent, the records support a score of 2. The patients parents worked actively and constructively with clinicians. Thus, the patient had a composite score of 17. This score correlates with intensive outpatient services. Therefore, residential treatment center services 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 sychiatry 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.