Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 

The parent of a 17-year-old male enrollee has requested reimbursement for residential treatment at Arivaca Boys Ranch from 5/26/16 through 2/13/17. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health condition. The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity for the services at issue in this clinical setting. Based on national guidelines, at the time of admission, the patient could have received services at a lower level of care. The 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. On 5/26/16, the patient met the following criteria prior to admission to the residential treatment facility. The patients score for risk of harm was a 1, which translates to low risk. Per the documentation, the patient had no history of suicide attempts. He did not have any suicidal ideation at the time of admission. He was screened at the RTC and was determined to be a no safety risk. The patients functional status was a 3, which is a moderate functional impairment due to a very conflictual relationship with his parents. The patient has been tardy to school and there were concerns that if his behavior continued, disciplinary actions would be taken by the school.  His comorbidity was also scored as a 3, which correlates to a significant comorbidity. Additionally, the patient had a comorbidity related to his diagnoses of oppositional defiant disorder, attention deficit hyperactivity disorder, and marijuana abuse. The patients substance abuse was having a significant adverse effect on his functioning. However, the patient appeared to be medically stable and did not have any medical conditions that required 24 hour monitoring. With regard to his recovery environment, his score is a 2, which relates to a mildly stressful environment. The patients parents were supportive. However, there was conflict in the home due to expectations from the parents and/or from the school. The conflict led to arguments and contributed to his oppositional behavior. The patients score with regard to his environmental support was a 2, because both parents were supportive. As for his score in the area of resiliency and treatment, the patient had limited ability to deal with stressors. He demonstrated a limited ability to follow through with recommendations from his prior outpatient therapist. As such, his score in the area of equivocal resiliency and response to treatment was a 3. He also scored a 3 in the area of acceptance and engagement at the time of admission. The patient did not want to be in care. However, it appears from the notes, the patient was able to develop positive relationships with the providers during his RTC stay. In sum, according to the CALOCUS scoring system, this patients composite score at the time of admission was 17.  The patient required treatment for his marijuana abuse, ODD, and ADHD, but his treatment could have been performed at a less restrictive environment like in an intensive outpatient program. It is standard of care to treat the patient in the least restrictive environment possible. Moreover, it was noted that the patient reported to the RTC staff that he wished to be treated in a less restricted environment. Based on the CALOCUS system as well as peer reviewed medical literature, this patient could have been treated in a less restricted environment. Therefore, residential treatment at Arivaca Boys Ranch from 5/26/16 through 2/13/17 was not medically necessary for treatment of this patient. 

Therefore, for the reasons stated above, the services at issue were not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.