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

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement and prospective authorization and coverage for residential treatment center services. Findings:  The physician reviewer found that  the residential treatment center services  rendered and  forward were not and are not medically necessary for treatment of the patients medical condition. Based on the documentation submitted for review, the patient could have been discharged to a less restrictive environment.  The patient had completed nearly four months of residential treatment and showed improvement. Although the patient remained impulsive, there was no mention of suicidal ideation, homicidal ideation, mania, or psychosis. There is no documentation of prior suicide attempts. Per the accepted criteria of the Child and Adolescent Level of Care Utilization System (CALOCUS), the patient scored a 19 . Based on the patients CALOCUS score, the enrollee meets criteria for intensive outpatient treatment services. The patient had a score of two (2) for self-harm due to having only fleeting thoughts of suicide. There was no record of any prior suicide attempts. The patient did not have any recent suicidal ideation. The patient had a score of three (3) for functional status due to having disturbances in his sleep, conflicted relationships with peers and adults, chronic deficits in interpersonal relationships, and gains in functioning which have been achieved only while participating in structured settings. The patient had a score of three (3) for co-morbidity given that the patient does have substance abuse problems with cannabis, and his substance use has stopped only due to highly structured settings. The patient scored a two (2) for environmental stress and one (1) for environmental support due to having some expectations for performance at home and school that create discomfort. His parents are concerned about the patient and are engaged with his recovery. The patient scored a four (4) for resiliency. The patient has poor resiliency and response to treatment. His previous treatments have not achieved complete remission of the patients symptoms despite intensive and repeated exposure to treatment. The patient scored a four (4) for acceptance and engagement as the patient typically has an adversarial relationship with providers. His total score is 19 which would meet criteria for intensive outpatient treatment services.  In sum, the patient could have been treated at a lower level of care. As such, the services at issue were not and are not medically necessary for treatment of the patients medical condition.   Final Result: The reviewers determined that the services at issue were not and are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: Physician reviewer number two 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.