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

Nature of Statutory Criteria/Case Summary:  The parent of an enrollee has requested reimbursement for services provided at Maple Lake Academy. Findings:  The physician reviewer found that to objectively 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 patient presented with some risk of harm, with a score of 2.  The patient had a history of some self-harm, but the notes were not specific in exactly how the patient would practice self-harm except that she stopped two weeks prior to being admitted to the residential treatment center. There is no history of any suicidal ideation or prior suicide attempts. There is no indication that the patient was physically or sexually aggressive with others. Regarding the functional status, the records support a score of 3. The patient demonstrated moderate functional impairment.  She had conflicted relationships with her parents and with peers. However, she is intelligent and does well academically. In terms of comorbidity, the documentation supports a score of 3. The patient had a comorbidity of autism spectrum disorder and anxiety. However, she did not have medical problems or substance use problems. Regarding environmental stress, the documentation indicates a score of 2. The patient had a mildly stressful environment.  She had expectations of her at home which the patient found distressing. She has interpersonal difficulties with family and peers. The patient scored 2 in terms of environmental support. She has supportive parents. Regarding resiliency and treatment, the records support a score of 3.  The patient had equivocal resiliency and response to treatment.  She had a limited ability to deal with stressors. The patient completed a wilderness therapy program prior to enrolling in the residential treatment center. Regarding acceptance and engagement, the patient scored 2. The notes indicate that she was cooperative with treatment for the majority of the time. Occasionally, the patient was sarcastic and would not participate.  Thus, the patient has a composite score of 17. Based on these criteria, the patient required treatment for autism spectrum disorder, anxiety, and depression, but this could have been accomplished in a less restrictive environment such as an intensive outpatient program. Therefore, services provided at Maple Lake Academy from the dates of service in question were not medically necessary for the treatment of this patient. 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 Physician 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.