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

Nature of Statutory Criteria/Case Summary: The enrollee has requested reimbursement and prospective authorization and coverage for residential treatment services for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that in order to objectively determine the appropriate level of care for the patient, the Child and Adolescent Level of Care Utilization System (CALOCUS) was utilized. This is an accepted, national standard for determining the appropriate level of care for children and adolescents. The patients risk of harm is scored a 3, which correlates to serious risk of harm. The patient has a prior history of self-harm. There were notations expressing some concern about the patients safety, however, the staff at the residential facility noted that the patient was safe enough to leave the premises on a pass and go home with the patients uncle over the weekend. The patients functional status is scored a 3, which correlates to moderate functional impairment. The patient has troubled relationships with her peers sending them text messages that she is going to cut her throat. However, it is noted that recent gains have been made in structured settings. The patients co-morbidity is scored a 3, with major depressive disorder, generalized anxiety disorder, and ADHD. The patient has epilepsy, which is well controlled with medications and does not require 24-hour monitoring. The patients recovery environment, which measures the patients environmental stress, environmental supports, resiliency and acceptance is scored a 3, given the patient moderately stressful environment. The patient has a supportive mother but the records indicate that she may have been exposed to patients adoptive fathers alcohol use. The patients environmental support is scored a 2, which correlates to a supportive environment. The patients mother is supportive of the patient in the patients recovery. The patients resiliency is scored a 3, equivocal response to treatment. Overall, prior treatment has not been successful in alleviating the patients symptoms. The patients acceptance and engagement is scored a 3, obstructive. For the most part, the patient is cooperative with staff and compliant with treatment. However, the patient will occasionally refuse to participate in therapy and will leave therapy sessions early. The patient resists accepting responsibility for the development of her problems. This patients total composite score according to the CALOCUS criteria is 20, which correlates to placement at a partial hospitalization program (PHP). As such, this patient can be treated at a less restrictive environment. The documentation shows that this patient has made improvements in her RTC treatment and the patient was permitted to leave the facility on a weekend pass with the patients uncle. This patient could be treated in a less restrictive environment like in a PHP setting, which still offers structure. In a PHP setting, the patients mood and potential substance use can still be monitored. The patient continues to need treatment for her major depressive disorder, generalized anxiety disorder, and ADHD, but treatment can be accomplished at a less restrictive environment. 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.