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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for the residential treatment center (RTC) services for treatment of the enrollees behavioral health issues. Findings:  The physician reviewer found that the progress notes indicate that this patient continued to experience PTSD symptoms throughout this admission. She has been withdrawn and her mood labile during therapy. Her family sessions appeared volatile at times and she has experienced numerous issues with peers on the unit. She demonstrated minimal coping skills on presentation and her insight and judgment were documented to be poor. She did not express active suicidal ideation during her stay, but her behaviors for the several months prior to her admission were dangerous and if not controlled, could have caused severe morbidity due to drug use and poor decision-making. In cases such as this, an evidence based instrument such as the child and adolescent level of care utilization system (CALOCUS) is useful in determining necessary level of care for children, to insure their level of care meets their individual needs at the least restrictive setting possible. Given this patients presentation, she is at serious risk of harm considering her recent pattern of excessive substance use resulting in harmful behaviors with no ability to restrict her use, her functional status is serious as she has experienced numerous disruptions in her home and school status due to her erratic behaviors, and she demonstrates major co-morbidity with substance abuse along with psychiatric symptoms that impair her ability to function. In addition, the patients recovery environment is highly stressful as the progress notes indicate that the patients home life is stressful, and her level of support is limited as the patients family has demonstrated limited ability to make changes during treatment. Moreover, the patients resiliency and treatment history are poor and the patient has not demonstrated any significant remission of symptoms in the past, her acceptance and engagement in treatment have been obstructive, and the patients engagement in treatment has been limited as the parents appear to work with providers but have difficulty creating a definition of the problem. This gives the patient a composite score of which correlates with secure 24-hour services with psychiatric management, which can be provided at the RTC level of care. The patient appears to have benefited from this admission as evidenced by her reduction in her PTSD symptoms as well as engagement with providers and resolution of some family issues that were causing continued symptoms. All told, the RTC services were and are medically necessary for treatment of this patients behavioral health issues. Final Result: The reviewer determined that the services at issue were and are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. 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.