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

Nature of Statutory Criteria/Case Summary: The parent of an enrollee requested reimbursement and prospective authorization and coverage for residential mental health treatment for a minimum of 45 day program for treatment of her behavioral health conditions.  Findings: The physician reviewer found that to 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.  In terms of risk of harm, the records support a score of 3.  This patient had a significant risk of harm. The patient had previous suicide attempts. She has experienced bullying in school and is very reactive to these situations. Regarding functional status, the records support a score of 3.  The documentation noted moderate functional impairment. The patient has conflictual relationships with her peers. She has been struggling with family therapy, although her parents are very supportive.  In terms of comorbidity, the records support a score of 2. The patient had a comorbidity of generalized anxiety disorder in addition to her bipolar disorder diagnosis. The patient appears to be medically stable. With regards to her recovery environment and environment stress, the records support a score of 2. The records document a mildly stressful environment. In terms of environmental support, the records support a score of 2.  The patient has supportive parents.  In terms of resiliency and treatment, the records indicate a score of 3. The patient had equivocal resiliency and response to treatment.  She has a limited ability to deal with stressors. Recovery has been maintained for moderate periods of time, but only with strong professional support. Developmental pressures create stress, which the patient feels are very overwhelming. In terms of acceptance and engagement, the records support a score of 2. It appears that the patient is cooperative and compliant with treatment recommendations from her medical providers. She is able to develop a positive relationship with care providers. Thus, the patient has a composite score of 17. Based on these criteria, the patient continued to require treatment for her bipolar disorder and generalized anxiety disorder, but she could have been treated in a less restrictive environment in an intensive outpatient program. Therefore, residential mental health treatment for a minimum of 45 day program was not and is 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 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.