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

Nature of Statutory Criteria/Case Summary: An 18-year-old female enrollee has requested reimbursement for residential treatment center services for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that To objectively determine the appropriate level of care for the patient, the case was examined using the Child and Adolescent Level of Care Utilization System (CALOCUS). This is an accepted, national standard for determining the appropriate level of care for children and adolescents. The patients risk of harm score is two (2), some risk of harm. The patient has a history of prior suicidal ideation. Some of these were in the context of alcohol use. The records do not indicate that the patient has had a suicide attempt. During the dates in dispute, the patient did not have any suicidal or homicidal ideation. The patients functional status score is three (3), moderate functional impairment. The patient has a long history of truancy from school. However, the patient is intelligent and when motivated, she is able to study and learn. The patient has interpersonal conflicts with parents over restrictions. The patients co-morbidity score is three (3), significant co-morbidity. The patient has a co-morbidity of persistent depressive disorder and anxiety disorder. The patient also has a history of lower back pain from a stress fracture. The patient has a history of drinking alcohol, but an alcohol use disorder has not been formally made. The patients recovery environment stress score is three (3), moderately stressful environment. The patient will frequently have interpersonal conflicts with her parents. The patients environmental support score is two (2), supportive environment. The patient has supportive parents who are willing to participate in treatment. The patients resiliency score is three (3), equivocal response to treatment. The patient has had an equivocal response to prior treatment. The patient has had periods of recovery which have been maintained for moderate periods of time, but only with strong professional support and at times, in structured settings. The patient has demonstrated an inconsistent capacity to deal with life stressors and maintain normal development. The patients acceptance and engagement scores is two (2), constructive. The patient is cooperative with treatment. The patient is able to develop a positive relationship with providers. The patient had a stable mood and was doing well. She has intermittent episodes of decreased mood, but overall reports were positive regarding her mood. Based on these criteria, the patient has a composite score of 18 and would meet criteria for an IOP. The patient had progressed enough to be discharged to a less restrictive environment. Therefore, residential treatment center services provided were not medically necessary for treatment of the patients medical condition.  Final Result: The reviewer determined that the services at issue were 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 expertise 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.