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

Nature of Statutory Criteria/Case Summary: The parent of a 16-year-old female enrollee has requested reimbursement for the psychiatric residential treatment center services. Findings:  The physician reviewer found that applying the Child and Adolescent Level of Care Utilization System (CALOCUS), the psychiatric residential treatment center services provided from 10/30/16 through 3/27/18 were not medically necessary to treat this patients behavioral health issues. The patient presented with some risk of harm due to a lack of active suicidal ideation at admission and during treatment (score 2). The patients was able to function as demonstrated by her ability to complete activities of daily living in an age appropriate manner (score 3). In the absence of active serious medical problems and no history of substance use, the patient presented with mild comorbidity (score 2). The patients recovery environment was mildly stressful given the issues with family relationships and a stable housing situation (score 2). In addition, the patient had a supportive recovery environment with family who is actively involved in treatment and attend family therapy sessions on a regular basis (score 2). Although the patient has shown limited response in prior treatment, she demonstrated substantial progress in the residential treatment center (score 3). The patient was accepting and engaged in therapy (score 2), and her parents were constructive and worked well with the patients providers (score 2). This gives the patients presentation a composite score of 18, which correlates with intensive outpatient services. According to the CALOCUS, the patient would need to have a score of 23-28 in order to require treatment in an RTC. Overall, the patient was described as cooperative and insightful in her therapy sessions. She had an instance of scratching herself with a rock, but there was no indication of suicide attempts. There was no indication of aggression or severe mood problems during the disputed timeframe. There was no indication that she was aggressive with peers. This patient was engaged in therapy and herself harm behaviors appeared minimal. It appears that her therapy could occur safely on an outpatient basis due to her high level of cooperation as well as her familys high level of cooperation. Current data indicates that effective self-harm reduction can occur with therapy available on an outpatient basis such as dialectical behavioral therapy.  All told, the psychiatric residential treatment center services provided from 10/30/16 through 3/27/18 were not medically necessary for treatment of this patients behavioral health issues.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.