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

Nature of Statutory Criteria/Case Summary: The parent an  enrollee has requested authorization and coverage for residential treatment center services provided from 8/16/18 through 8/27/18. The Health Plan has denied this request indicating that the requested services were not medically necessary for treatment of the enrollees moderate major depressive disorder and substance abuse.At issue in this case is whether the requested residential treatment center services provided from 8/16/18 through 8/27/18 were medically necessary for treatment of the enrollees behavioral health condition.During the dates of 8/16/18 through 8/27/18, the patient showed cooperative behavior and treatment. The progress notes indicate that he was open and honest in regards to his feelings about his past substance use, his mood, and his anger towards his parents. A majority of his sessions focused on his disposition and his placement plans. It appeared that he initially was to go to a military academy but this did not occur and instead he went to a sustained recovery program.  The patient did not display aggression towards peers or staff during this time frame.  He did not express any significant mood or anxiety symptoms. He did not express any symptoms of psychosis. The CALOCUS scoring below is for the disputed time frame as assessed by the patient symptoms.1)   Risk of harm--- low (1), the medical records indicate that the patient was not actively suicidal any time after the recommended approval timeframe, the progress notes indicate the patient was not engaging in self-harm behaviors or expressing suicidal ideation. 2)    Functional status--- mild(2), the patient has had some issues with level of function but the progress notes indicate significant improvement after a period of deterioration.3) Co-Morbidity---minor (2), the patient does not have active medical problems and has a history of moderate cannabis use issues. He described continued cravings but there was no documentation of any withdrawal symptoms from any substances.4A) Recovery environment, level of stress---mild (2), the patient was noted to have interpersonal conflict with the family members due to his inability to return home. However the progress notes document that his relationship and phone calls with his family were good.4B) Recovery environment, level of supportsupportive (2), the patients parents are involved in treatment on a regular basis.5) Resiliency and Treatment historymoderate/equivocal (3), it appears that the patient has had good response to a short period in the residential treatment center (prior to the disputed dates).  His presentation during the disputed time frame indicates that he was very cooperative in treatment and any mental health symptoms he had were mild in nature. The records do not describe in any significant detail any past treatment history.6A) Acceptance and engagement, child/adolescent---constructive (2), the patient participates in therapy actively and his insight and judgment were noted to be good throughout treatment as judged by his insight into his substance use as well as his relational issues.6B) Acceptance and Engagement, Parent ---constructive (2), the parents work actively and constructively with clinicians on a regular basis. This gives the patients presentation a composite score of 16. This score correlates with a treatment intensity level of two which correlates with `Outpatient Services`. This score is judged by the acuity of the patients symptoms and environment during the period under dispute at the residential treatment center, as of the date of the denied health plan authorization. According to the CALOCUS the patient would need to have a score of 23-28 in order to require treatment in a residential treatment center setting. Therefore, the requested services were not medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested services were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheldCredentials/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.