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

Nature of Statutory Criteria/Case Summary:  The patients parent has requested reimbursement for the residential treatment center (RTC) provided for treatment of the enrollees post-traumatic stress disorder (PTSD), anxiety and attention deficit hyperactivity disorder (ADHD). Findings:  The physician reviewer found the available progress notes indicate that the patient reported symptoms of depression and anxiety that was in the mild category. During her admission, the patient was noted to be cooperative and benefiting from her therapies while at the RTC. The progress notes did not indicate the patient was aggressive with her peers or staff while at the RTC, the patient did not have any active suicidal ideation or attempted suicide. The patient could have been treated with dialectical behavioral therapy (DBT) on an outpatient or intensive outpatient basis. This type of therapy has been proven to be beneficial in reducing mood symptoms, emotional dysregulation and suicidal behavior in adolescents. In cases such as this, an evidence based instrument such as the Child and Adolescent Level of Care Utilization System (CALOCUS) is indispensable in determining necessary level of care, to insure their level of care meets their individual needs at the least restrictive setting possible. This patient was at some risk of harm (score 2) due to the patients history of impulsive actions and behaviors. However, the medical records indicate that the patient was not actively suicidal anytime during the RTC stay and the patient was not noted to be suicidal on admission. The patient demonstrated some issues in terms of functional status (score 3) as she had some issues with inappropriate relationships. The patient did not have any active serious medical problems or any significant substance use issues (score 2), and her recovery environment was mildly stressful (score 2) as the patient has a positive recovery environment and a stable housing situation. The patients recovery environment was supportive (score 2) as the patients parents were continually involved in treatment as evidenced by their participation in frequent family therapy sessions. The patient demonstrated equivocal response to treatment (score 3) due to no significant and noted treatment successes. The patient was constructive in treatment (score 2) as she participated in therapy and used coping skills learned in therapy. The patients parent worked actively and constructively with providers (score 2). This gives the patients presentation a composite score of 18 which correlates with intensive outpatient services. In summary, the patient could have been safely and effectively treated in a less restrictive setting. Accordingly, the RTC 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 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.