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 services. The submitted documentation fails to demonstrate the medical necessity of the services at issue. This patient engaged in therapy and expressed her anxiety with regards to returning home. The records did not indicate volatile interactions between the patient and her family. The patients parents mentioned that they were concerned that the patient was picking up negative behaviors from her peers in the residential treatment center. The patients parents appeared calm and insightful during therapy sessions. The patient was noted to be cooperative and insightful in her therapy sessions. There was no indication of suicide attempts or suicidal ideation. Her main issues appeared to be continued depression as well as anxiety around past traumatic events. There was no indication of aggression or severe mood problems during the disputed timeframe. There was no indication that she was aggressive with peers. The records do not indicate that the family had tried functional family therapy (FFT) which is an evidence-based treatment in this setting. Per the records, this patient could have been treated with less restrictive therapeutic services. The American Academy of Child and Adolescent Psychiatry and American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) is indispensable in determining necessary level of care for children. In terms of risk of harm, the records support a score of 2 due to the patients episodic scratching behaviors that did not seem to be suicide attempts. With regards to functional status, the records support a score of 3. The patient was able to complete activities of daily living in an age appropriate manner. In terms of comorbidity, the records support a score of 2. The patient does not have active serious medical problems, and her substance use appeared infrequent. With regards to level of stress of the recovery environment, the records support a score of 2. The patient has issues with family relationships, but she has a stable housing situation. In terms of level of support of the recovery environment, the records support a score of 2. The patients family is actively involved in treatment and attends family therapy sessions on a regular basis. With regards to resiliency and treatment history, the records support a score of 3. This patient has had equivocal treatment response in the past prior to residential treatment, but she has had good progress in the residential treatment center. In terms of acceptance and engagement of the patient, the records support a score of 2. The patient participates in therapy and is cooperative. With regards of acceptance and engagement of the parents, the records support a score of 2. The patients parents work actively and constructively with clinicians. Thus, this patient has a composite score of 18. This score correlates with intensive outpatient treatment. Therefore, residential treatment services were not and are not medically necessary for the treatment of this patient. 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 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.