Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 


An 18-year-old male enrollee has requested reimbursement for residential treatment services provided from 8/05/15 through 11/30/15. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health conditions. The physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the services at issue. To objectively determine the appropriate level of care for the patient, the case was examined using the Child and Adolescent Level of Care Utilization System (CALOCUS). This is an accepted, national standard for determining the appropriate level of care for children and adolescents. In terms of risk of harm, the records support a score of 2. The patient had some risk of harm.  He has a history of intermittent suicidal ideation and has a history of writing a suicide letter.  The patient denied any current or future suicide plans at the residential treatment center. With regards to functional status, the records support a score of 3.  The patient had moderate functional impairment during the dates of service at issue.  The patient was increasing his substance use of marijuana and was failing out of school. Per documentation, he did have struggles interacting with staff at the beginning of his stay at the residential treatment center.  In terms of comorbidity, the records support a score of 3.  The patient had comorbidities of concussions, chronic nausea and vomiting, and cannabis use. His chronic nausea and vomiting is thought to have led the patient to increase his substance use due to marijuana helping with his nausea and vomiting. The patients marijuana use has had a significant impact on his presenting problems. With regards to the patients recovery environment, the records support a score of 2 in terms of environmental stress.  The patient had a good relationship with his mother and father. In terms of environmental support, the records support a score of 2.  The patient has supportive parents who are willing to participate in treatment if asked to do so.  With regards to resiliency, the records support a score of 3. The patient had equivocal resiliency and response to treatment.  In terms of acceptance and engagement, the records support a score of 3. At the time of admission, the patient expressed his desire to be treated in a less restrictive environment. The patient was passive in his treatment and limited his interaction with the staff. Thus, the records support a composite score of 18. Based on these criteria, the patient would meet criteria for an intensive outpatient program and could have been treated in a less restrictive environment. The patient continued to need treatment, but this could have been accomplished at a lower level of care. Therefore, residential treatment services provided from 8/05/15 through 11/30/15 were not medically necessary for the treatment of this patient. Therefore, the services at issue were not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.