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

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting reimbursement for residential treatment center services. The enrollee has major depressive disorder, generalized anxiety disorder, substance abuse, attention deficit hyperactivity disorder (ADHD), and non-verbal learning disorder and received outdoor behavioral health treatment. He had been in treatment at a different facility, but his therapist noted he did not make progress and needed a higher level of care. The recommendation was for a high level of activity and involvement in a variety of social, recreational and outdoor activities. The enrollees therapist indicates given the persistence of symptoms over the years, with increasing severity and escalation to suicidal ideation and self-harm, and despite continued outpatient therapy and medication monitoring, a more intensive level of treatment became necessary for the enrollee. Although he made significant progress in the program, he still remained in a fragile state. A residential level of care was necessary to achieve significant and lasting improvement of his condition. The enrollee entered an initial program. However, the clinical team decided he was not a good fit for the program due to a lack of social awareness. His discharge diagnosis was dysthymia. He transitioned to the wilderness program, and was discharged after completing the program. The enrollee progressed in his ability to be open with his parents about his drug use and about accepting personal responsibility for his behaviors. He was participating in family, individual and group therapy sessions. There were no reports about him being aggressive or inappropriate with other students, refusing to follow programs schedule, refusing hygiene or refusing to participate in assigned tasks. He continued with this attitude throughout his stay at the RTC and it appears he could have transitioned to a less restrictive setting. The Level of Care Utilization System (LOCUS), a level of care assessment tool widely used by clinicians throughout the country to support accurate level of care recommendations was utilized in this review. For risk of harm, the enrollees score is 3, due to no active suicidal/homicidal ideation, but extreme distress and/or a history of suicidal/homicidal behavior exists. For functional status, the enrollees score is 4, due to serious deterioration of interpersonal interactions, with consistently conflictual or otherwise disrupted relations with others, which may include impulsive or abusive behaviors. There are serious disturbances in vegetative status such as weight change, disrupted sleep, or fatigue that threaten physical well-being. There is an inability to perform close to usual standards in school, work, parenting, or other obligations. These responsibilities may be completely neglected on a frequent basis or for an extended period of time. For comorbidity, the enrollees score is 3, due to significant psychiatric symptoms and signs that are present which are themselves somewhat debilitating, and which interact with and have an adverse effect on the course and severity of any co-existing substance use disorder. For recovery environment level of stress, the enrollees score is 3, due to significant discord or difficulties in family or other important relationships or alienation from social interaction. There is easy exposure and access to alcohol and drug use. There is a pressure to perform that surpasses the enrollees ability to meet obligations in a timely or adequate manner. For recovery environment level of support, the enrollees score is 2, since supportive resources are not abundant, but are capable of and willing to provide significant aid in times of need. For treatment and recovery history, the enrollees score is 3, as previous or current treatment has not achieved complete remission of symptoms or optimal control of symptoms. For engagement and recovery status, the enrollees score is 2, as the enrollee shows some recognition of his personal role in recovery and accepts some responsibility for it. The enrollees LOCUS was 20, which correlates with Level IV, medically monitored non-residential services. However, the score of 4 on dimension II indicates he required a higher level of care, Level V, residential treatment center (RTC). However, the enrollees functional status improved to moderate impairment, resulting in a score of 3, which was appropriate for transition to a lower level of care. Final Result: The reviewer determined that the requested services were partially 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.