Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 


The parent of a 16-year-old female enrollee has requested reimbursement and prospective authorization and coverage for mental health residential treatment from 12/07/17 forward. The Health Insurer has denied this request indicating that the services at issue were not and are not medically necessary for treatment of the enrollees behavioral health conditions. The physician reviewer found that the Child and Adolescent Level of Care Utilization System (CALOCUS) is an accepted, national standard for determining the appropriate level of care for children and adolescents.  In terms of risk of harm, the records support a score of 3. The patient had one prior suicide attempt on 4/03/17. On 12/08/17, the patient did not have any suicidal ideation. There is a concern that the patients substance use could result in an accidental overdose. With regards to functional status, the records support a score of 3. The patient had moderate functional impairment. She has conflicted relationships with her parents and peers. The patient has a history of running away from school and home. She has made modest behavioral improvements during her residential treatment center stay. In terms of comorbidity, the records support a score of 3. The patient has comorbidities of major depressive disorder, attention deficit/hyperactivity disorder, cannabis use disorder, and alcohol use disorder. The patient does not have any major medical problems which would require 24-hour monitoring. In terms of environmental stress, the records support a score of 3. The patients family situation is disrupted. With regards to environmental supports, the records support a score of 3. There is limited support in her environment. The patients father would like to be involved in the patients care, but he lives in Canada. Her mother is supportive, but the patient does not live with her. In terms of resiliency, the records support a score of 3. The patient has had equivocal resiliency and response to treatment. Her previous treatment has not managed her substance use and depression. With regards to acceptance and engagement, the records support a score of 3. The patient has trouble with authoritarian figures. She has difficulty committing to a treatment plan and has difficulty committing to future sobriety. She can be redirected and will engage at times and will apologize for previous behavior during times of increased insight. Thus, the patient has a composite score of 21. Based on these criteria, the patient meets criteria for a partial hospitalization program (PHP) and could be treated in a less restrictive environment. The patient continued to need treatment for her major depressive disorder, attention deficit/hyperactivity disorder, cannabis use disorder, and alcohol use disorder, but this could have been done in a less restrictive environment. Thus, mental health residential treatment from 12/07/17 forward was not and is not medically necessary for the treatment of this patient. Therefore, the services at issue were not and are not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.