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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment center (RTC) 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. As of the date in dispute, the patients risk of harm score, serious risk of harm. The patient has a history of four prior suicide attempts. The patient sent an email to her parents stating that she was going to kill herself. The patient then admitted that she was stealing plastic knives and staples to administer self-harm. The patient was put on a one-on-one supervision. The patients functional status score, moderate functional impairment. The patient has conflicted relationships with her peers and parents. She is able to do some school work, but only under strict supervision and structure. The patient has chronic severe deficits in his interpersonal relationships and her ability to engage in socially constructive activities. The patients co-morbidity score, significant co-morbidity. The patient has a co-morbidity of persistent depressive disorder with psychosis, ADHD, PTSD, cocaine use disorder, alcohol use disorder, and cannabis use disorder. However, the patient does not have any medical problems which require 24-hour monitoring. The patients recovery environmental stress score, moderately stressful environment. The patient has struggles with her home life. The patient is distant from her parents. The patient has expectations for performance at school and family life which create discomfort. The patients environmental support score, limited support in the environment. The patient has supportive parents; however, the patient has distanced herself from her parents. She will act out when she feels ignored. The patients resiliency score, poor resiliency and response to treatment. The patient has had prior treatment for her psychiatric conditions. The patient continues to have active symptoms including flashbacks, hallucinations, ongoing suicidal ideation, and emotional lability. The patients acceptance and engagement score, obstructive. The patient has difficultly forming positive relationships with providers. At times, the patient will cooperate, but at other times, the patient will get into verbal altercations with staff. Based on these criteria, the patient has a composite score, and met the criteria for residential stay. The patient continues to have suicidal ideation with concerning behaviors which required a one-on-one. The patient had to sleep in a common area due to not feeling safe. She continues to have a labile affect, flashbacks, hallucinations, and psychotic episodes. Therefore, the RTC services provided have been established as medically necessary for treatment of the patients medical condition.  Fulfills requirements of (1374.33)(h)(1)(H) and (K)Final Result: The reviewer determined that the services at issue were 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 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.