Appeal type: Medical Necessity
Decision: Overturned 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 eating disorders and mental health treatment program. Findings:  The physician reviewer found that The patient was noted to continue to have depression symptoms and the progress notes indicated he had extremely limited insight into his need for treatment. The progress notes indicate he complained about his treatment and the staff at the treatment center. He appeared in minimally cooperative in treatment and has not gained any weight. He expressed numerous problems with his relationship with his family and the progress notes reflect the fact that his father does not understand the patients illness. The patient had a history of daily cannabis use and has failed treatment at lower levels of care. Applying Child and Adolescent Level of Care Utilization System (CALOCUS), this patient meets the criteria for treatment at the RTC level of care. The patient is at significant risk of harm (score 3) due to his repetitive suicidal ideation and his functional status is significantly disrupted (score 4) with numerous disruptions in treatment due to continued eating disorder symptoms. The patient has moderate co-morbidity (score 3) with reported daily cannabis use with no desire to stop. The patients recovery environment is highly stressful (score 4) as the patients home life is stressful do to the strained relationship with his parents. He has minimal support (score 4) as his primary caretakers are reported to have difficulty providing emotional support in an appropriate manner. The patient has demonstrated negligible response to prior treatment (score 5) due to extremely minimal positive treatment response in the past as well as current difficulties with weight maintenance. Moreover, the patient has been adversarial in treatment (score 4) with minimal insight into his treatment needs, and he appears to blame treatment staff for his lack of success in treatment. The patients parents appear to work with providers, but have difficulty creating a definition of the problem (score 3). These findings give the patient a composite score of 30, which correlates with secure 24-hour services with psychiatric management. An example of this is a hospital or secure RTC. Thus, the patient meets the criteria for RTC placement according to the CALOCUS. Since the patient has not made adequate treatment progress and continues to demonstrate unsafe behaviors, the residential eating disorders and mental health treatment program services were and are medically necessary for treatment of his behavioral health condition. Final Result: The reviewer determined that the services at issue were and are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in psychiatry with sub-specialty certification 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.