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

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) program services. 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. The patients risk of harm score is one (1), low risk of harm. The patient does not have a history of any suicide attempts. He does not have a history of any self-harm or any suicidal ideation. He does not use any illicit substances. The patients functional status score is three (3), moderate functional impairment. The patient is described as having high functioning autism. The patient has good grades and obeys teachers at school. He is defiant at home and will hide and break things. He will socially isolate and spend most of his free time on the computer. The patient has stopped communicating with his parents. Due to his autism spectrum disorder, the patient has chronic severe deficits in his interpersonal relationships with others and his ability to engage in socially constructive activities. The patients co-morbidity score is three (3), significant co-morbidity. The patient has a significant co-morbidity of autism spectrum disorder which contributes to developmental delays. The patient does not have any medical co-morbidities. The patient does not abuse alcohol or illicit substances. The patients recovery environmental stress score is three (3), moderately stressful environment. The patient has a supportive family. However, the patient is oppositional. He will have his computer taken away as a form of discipline which frustrates the patient and causes stress and conflicts with his parents. The patient has decided not to communicate with his parents or his sibling. The patients environmental support score is two (2), supportive environment. The patient has supportive parents who are willing to participate in treatment.  The patients resiliency score is two (2), significant response to treatment. The parents report that prior outpatient therapy treatment was helpful for the patient and that the frequency of his tantrums decreased after the treatment. The patients acceptance and engagement score is three (3), obstructive. The patient has trouble having a positive, therapeutic relationship with providers. He will frequently not participate in treatment activities and at times will be defiant and refuse to attend treatment. Based on these criteria, the patient has a composite score of 17 and meets criteria for an intensive outpatient program (IOP) and could be treated in a less restrictive environment. The patient requires treatment for his autism spectrum disorder, but this could be accomplished at a less restrictive environment. Therefore, the RTC services have not been established as medically necessary for treatment of the 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 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.