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

Nature of Statutory Criteria/Case Summary: The parent of a 16-year-old female enrollee has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) services. Residential treatment is typically used for acute stabilization and has not been demonstrated in the evidenced-based literature to be effective for long-term treatment. The records provided for review do not indicate that the family has tried functional family therapy (FFT) which is an evidence-based treatment for the patients condition. The author noted that FFT has proven highly successful in decreasing violence, drug abuse/use, conduct disorder and family conflict and in reducing residential treatment placements and juvenile involvement with the corrections system. Family therapy is essential to this patients success due to the recommendations to receive this therapeutic intervention, per her evaluations and clinical presentation. The literature supports outpatient treatment as well as family therapy in managing suicidal ideation and behaviors for adolescents. In addition, the current literature indicates that effective self-harm reduction can occur with therapy on an outpatient basis such as DBT. Applying the child and adolescent level of care utilization system (CALOCUS), this patient was and is a candidate for treatment in the intensive outpatient setting. The patients risk of harm includes episodic outbursts and overall level of impulsive behaviors, but no active suicidal ideation or other behaviors or thoughts (score 2). The patients functional status was moderate (score 3) as she had minimal disruption and is able to complete her activities of daily living in an age appropriate manner. The patient presents with no co-morbidity (score 1) as she has no active serious medical problems. The patients recovery environment is mildly stressful (score 2) given her issues with family relationships, but she has a stable housing situation. The patients recovery environment is supportive (score 2) as her family is actively involved in treatment and attend family therapy sessions on a regular basis. The patient has demonstrated limited response to treatment (score 3), has been constructive in treatment (score 2), and her parents work actively with the patients providers (score 2). This gives the patients presentation a composite score of 17 which correlates with intensive outpatient services. 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. Thus, the RTC services provided were not and are not medically necessary for treatment of this patients medical condition. 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 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.