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

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for intensive in-home family treatment sessions four times a week for 9 to 12 months. The Child and Adolescent Level of Care Utilization System (CALOCUS) provides a framework for determining the clinically appropriate level of care for a child or adolescent in mental health treatment. With regard to risk of harm, the records support a score of 4. The patient had a serious risk of harm, due to persistent and ongoing suicidal ideation with thoughts of wanting to hang herself and a history of superficial cutting. The patient had been hospitalized multiple times for suicidal ideation and was noted to be impulsive with poor judgment.In terms of functional status, the records support a score of 4. The documentation noted serious functional impairment due to multiple hospitalizations. The patient expressed significant difficulties regulating her emotions. The patients current mental health issues and numerous psychiatric hospitalizations have likely interfered with her academic progress and achievement. With regard to comorbidity, the records support a score of 2. The patient had minor comorbidity, due to urinary incontinence, constipation, and a history of concussion. In terms of level of stress of the recovery environment, the records support a score of 4. The patient had a highly stressful environment due to family stress, a history of abuse, a recent breakup, and issues with peers. The records noted that the patients home was a trigger. The patient reported that she wanted to leave home and go to the hospital as a form of escape. The patients parents reported feeling burned out by the patients behaviors and high needs. With regard to level of support of the recovery environment, the records support a score of 2 due to her parents involvement in seeking treatment for her. In terms of resiliency and treatment history, the records support a score of 4. The patient had poor response to treatment and recovery management due to persistent symptomatology despite multiple treatment attempts at several levels of care, including multiple hospitalizations, intensive outpatient programs, outpatient psychotherapy twice weekly, and ongoing medication management. With regard to treatment acceptance and engagement, the records support a score of 3. The records noted that following her latest hospitalization, the patient was quick to report improvement, suggesting that she may be minimizing or rationalizing her behaviors and a superficial level of engagement.Thus, the patient has a total score of 23. The records support a 4 in terms of risk of harm and functional status. In this case, the recommended level of care is medically monitored residence-based services. With the functional impairment and elevated risk of harm noted, the patient meets CALOCUS 5b extended stay criteria. This is not consistent with the level of care that the patient has requested. In this patients case, intensive in-home family treatment sessions four times a week for 9 to 12 months are not in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the requested services are not clinically appropriate in terms of type, frequency, extent, site, and duration. The requested services are primarily for the economic benefit of the health care service plan and subscribers or for the convenience of the patient, treating physician, or other health care provider. Therefore, intensive in-home family treatment sessions four times a week for 9 to 12 months are not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.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.