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

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for residential treatment center (RTC) services for a minimum of six months, up to a year. The Child and Adolescent Level of Care Utilization System (CALOCUS) provides a framework for determining the clinically appropriate level of care for a child or adolescent in mental health treatment.With regard to risk of harm, the records support a score of 3. The patient had a significant risk of harm, due to a history of and presence of substance abuse with cannabis, methamphetamines, and benzodiazepines, along with suicidal ideation, poor impulse control, and parent-child relationship issues.    In terms of functional status, the records support a score of 2. The documentation noted mild functional impairment. At the time of discharge from inpatient hospitalization, the patient reported improved mood and did not endorse symptoms of depression or anxiety, or disturbance in his sleep, energy, or appetite. With regard to comorbidity, the records support a score of 3. The patient had significant comorbidity, due to the presence of substance abuse, ADHD, and depression.  In terms of level of stress of the recovery environment, the records support a score of 3. The patient had a moderately stressful environment due to concerns of the patient being exposed to his mothers use of prescription Xanax and significant interpersonal challenges with his mother. With regard to level of support of the recovery environment, the records support a score of 3 due to his mothers limited ability to respond appropriately to the patients needs, such as ambivalence in driving the patient to PHP.In terms of resiliency and treatment history, the records support a score of 4. The patient had poor response to treatment and recovery management due to continued struggles with sobriety and chronic suicidal ideation despite medication trials, two inpatient hospitalizations, and three months in an RTC. With regard to treatment acceptance and engagement, the records support a score of 3. The patients mother reported stress at driving the patient daily to PHP level of care for the patient. Thus, the patient has a total score of 21. In this case, the recommended level of care is medically monitored nonresidential services. In this patients case, RTC level of care is not in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the requested services are not clinically appropriate in terms of type, frequency, extent, site, and duration. The requested services are primarily for the economic benefit of the health care service plan and subscribers or for the convenience of the patient, treating physician, or other health care provider. Therefore, RTC services for a minimum of six months, up to a year, are not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested services 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.