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

Nature of Statutory Criteria/ Case Summary:  The enrollees parent is requesting reimbursement for residential treatment center (RTC) level of care services. The enrollee entered the residential treatment center (RTC) level of care due to suicidal thoughts, urges and actions of self-harm, and depression. The enrollees parents indicate she is secretive about her suicidal ideations. She has difficulty controlling her emotions and becomes impulsive and angry when she does not get what she wants. The enrollee has a history of two suicide attempts and five hospitalizations/treatment programs. She reports a history of self-harming behaviors since sixth grade, with the last self-harming behaviors one month prior. She has no history of alcohol or drug use. There are no medical or legal issues. During her stay at the RTC, the enrollee was compliant with her medications. Her psychiatrist considered increasing the Sertraline, but records do not indicate this was done. Her engagement during individual and family therapy was variable. Sometimes she was withdrawn, while at other times she actively participated. The Child and Adolescent Level of Care Utilization System (CALOCUS) level of care assessment tool was used in this case review. For risk of harm, the enrollees score is 3, indicating a significant risk, due to significant current suicidal or homicidal ideation with some intent and plan, with an ability for the child or adolescent and his/her family to contract for safety and carry out a safety plan. The child or adolescent expresses some reason not to carry out such behavior. The enrollee has no active suicidal or homicidal ideation, but has extreme distress and/or a history of suicidal/homicidal behavior. There is an indication or report of incidents of acting without thinking, or physically or sexually aggressive actions that endanger self or others, breaking laws, self-mutilation, running away, fire setting, and violence towards animals. For functional status, the enrollees score is 2, due to some evidence of minor failures of function in any of several areas of living; school, family, peers. These periodic or momentary failures are time limited. There are occasional episodes in which some aspects of self-care/hygiene or physical function are disrupted. For comorbidity, the enrollees score is 1, as she has no evidence of medical illness, substance abuse, developmental disability, or psychiatric disturbances apart from the presenting condition. For recovery environment level of stress, the enrollees score is 1, due to the absence of significant or enduring difficulties in the environment; life circumstances are stable, and she has had an absence of recent transitions or losses of consequence. She has had no change in school, residence, or marital status of parents, or no birth/death of family members. Her living environment is conducive to normative growth, development, and recovery. For recovery environment level of support, the enrollees score is 2, since the continuity of her family or primary caretakers is only occasionally disrupted, and/or relationships with family or primary caretakers are only occasionally inconsistent. Family/primary caretakers are willing and able to participate in treatment if requested to do so and have the capacity to effect needed changes. For resiliency and treatment history, the enrollees score is 4, since the enrollee has demonstrated frequent evidence of innate vulnerability under stress and difficulty resuming progress towards the expected developmental level. Previous treatment has not achieved complete remission of symptoms or optimal control of symptoms even with intensive and/or repeated exposure to treatment. For treatment acceptance and engagement, the enrollees score is 3, due to an ambivalent, avoidant, or distrustful relationship with clinicians and other care providers. The enrollee minimizes or rationalizes distressing behaviors and consequences, and is unable to accept others definition of the problem and its consequences. The enrollees composite CALOCUS score is 16, which correlates with level III, High Intensity Community Based Services. However, having a score of 4 on dimension V requires a higher level of care, which is level IV, Medically Monitored Community Based Services.  The medical evidence does not support the RTC level of care. Final Result: The reviewer determined that the requested services were not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in psychiatry and 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 similar medical condition.