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

Nature of Statutory Criteria/ Case Summary:  The enrollees parent is requesting reimbursement for residential treatment center services. The enrollee has diagnoses of major depressive disorder, recurrent episode, severe; separation anxiety disorder; post-traumatic stress disorder (PTSD); and alcohol use disorder, moderate, in early remission. He struggles with severe anxiety and depression, which impact scholastic activities. He experienced significant trauma with the loss of his father two years prior. He would sometimes drink alcohol with friends and he has a history of black-outs. He tried marijuana once. He has no history of legal issues. The patient was admitted for residential treatment. The progress note from this day indicates the patient describes his mood as okay, affect was euthymic, and thought process was linear. He did not exhibit SI, homicidal ideation (HI), or delusions. His cognition was grossly intact. His insight and judgment were poor. At the residential treatment center (RTC), he participated in art therapy, music therapy, drama therapy, equine therapy, family therapy, group therapy, individual therapy, guided imagery and neurofeedback. No psychotropic medications were initiated during this admission. He demonstrated improvement in mood and sleep and was looking forward to going back to school. He was not suicidal or homicidal. He interacted in talk therapy, empty chair, and mindfulness in order for him to understand his feelings and be able to self-regulate. The patient used medication, breathing, muscle relaxation and music as coping skills and significantly decreased his anxiety. He was able to come to peace with his fathers death. The progress note before discharge described his mood as good and his affect as congruent and appropriate. His thought process was fair, with no SI, HI, or delusions. His insight and judgment were fair. The enrollee completed 41 days of treatment and was ready for step-down. The Child and Adolescent Level of Care Utilization System (CALOCUS), developed as a collaboration between the American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists, is a level of care assessment tool used by behavioral health managers and clinicians to support accurate level of care recommendations. This tool was utilized in this review. The enrollees CALOCUS scoring does not support the medical necessity of RTC level of care services. For risk of harm, the enrollees score is 3, due to no active suicidal or homicidal ideation, but extreme distress and/or a history of suicidal/homicidal behavior. For functional status, the enrollees score is 3, due to significant disturbances in physical function that do not pose a serious threat to health. School behavior has deteriorated to the point where the child/adolescent has faced some school disciplinary action and is at risk for placement in an alternative school program. Recent gains and/or stabilization in functioning have been achieved while participating in treatment in a structured, protected, and/or enriched service. For comorbidity, the enrollees score is 3, due to substance abuse being present, with significant adverse effects on functioning and on the presenting condition. For recovery environment level of stress, the enrollees score is 2, due to a significant transition requiring adjustment, such as a change in household members, or a new school or teacher. Expectations for performance at home or school create discomfort. The potential for exposure to substance use exists. For recovery environment level of support, the enrollees score is 2, due to the continuity of family or primary caretakers is only occasionally disrupted, and/or relationships with family or primary caretakers are only occasionally inconsistent. Family/primary caretakers are willing and able to participate in treatment if requested to do so and have the capacity to effect needed changes. For resiliency and treatment history, the enrollees score is 3, due to developmental pressures and life changes have caused some deterioration in function. For acceptance and engagement the score is 2, due to the enrollee being able to develop a trusting, positive relationship with clinicians and other care providers. The enrollees composite CALOCUS score is 18, which correlates with high intensity community based services.Final Result: The reviewer determined that the requested services were not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in psychiatry and 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 similar medical condition.