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

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) services at a CALOCUS Level 5C facility.  Findings:  The physician reviewer found that he records support a score of 3. The patient had a significant risk of harm, due to continued symptoms of anxiety and depression, and as the records noted that the patient would still be vulnerable to relapse outside of a structured setting. The records noted that the patient no longer had active suicidal ideation and was participating in treatment. His insight was noted to be appropriate. In terms of functional status, the records support a score of 3. The documentation noted moderate functional impairment due to the patients ability to participate in treatment and manage a daily routine, although the records noted that the patient reported fear regarding an ability to maintain sobriety. With regard to comorbidity, the records support a score of 3. The patient had significant comorbidity, due to chronic symptoms of depression and anxiety, and the presence of  substance abuse.  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 struggles in avoiding exposure to substance use and its effects.With regard to level of support of the recovery environment, the records support a score of 3 due to his parents limited ability to provide the level of support required. In terms of resiliency and treatment history, the records support a score of 3. The patient had moderate or equivocal or response to treatment due to motivation for sobriety, although he continues to struggle with symptoms of depression and anxiety. With regard to treatment acceptance and engagement, the records support a score of 2. The patient appeared collaborative and engaged, although unsure of his ability to remain sober.Thus, the patient has a total score of 21. In this case, the recommended level of care is medically monitored community-based services. This is inconsistent with the level of care that the patient received and is receiving at the RTC. In this patients case, RTC level of care was not and is not in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the services at issue were not and are not clinically appropriate in terms of type, frequency, extent, site, and duration. Therefore, RTC services at a CALOCUS Level 5C facility were not and are not medically necessary for the treatment of this patient. Final Result: The reviewer 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: The reviewer is board certified in 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.