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

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement for residential treatment services. The submitted documentation fails to demonstrate the medical necessity of the services at issue. During the dates of service in dispute, the patient showed cooperative behavior and attitude. The progress notes indicated that he was open and honest with regards to his feelings about his peers at the treatment center, who appeared to be his major focus of stress. He did not display aggression towards peers or staff during the disputed timeframe. The patient did not express significant depression or anxiety symptoms. He did not express symptoms of psychosis. He indicated that his medications were working for him, and his focus was good.In cases such as this, an evidence-based instrument such as American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) assists in determining necessary level of care for children. In terms of risk of harm, the records support a score of 1. The medical records indicate that the patient was not actively suicidal during the disputed timeframe, and he did not engage in self-harm behaviors. With regards to functional status, the records support a score of 2. The patient had some issues with level of function prior to residential treatment center placement, but the progress notes indicate significant improvement after a period of deterioration. The progress notes indicate he performed his activities of daily living as well as chores at the treatment center on a regular basis. He was also noted to help peers with their chores. In terms of comorbidity, the records support a score of 2. The patient had asthma issues which were exacerbated by wildfires in the area near the residential treatment center. The records did not indicate a history of substance use, and he did not have a substance use diagnosis. With regards to level of stress of the recovery environment, the records support a score of 2. The patient was not noted to have interpersonal conflict with the family members. In terms of level of support of the recovery environment, the records support a score of 2. The patients parents were involved in treatment on a regular basis. With regards to resiliency and treatment history, the records support a score of 3. The patient had a good response to a short period in the residential treatment center prior to the disputed dates.  His presentation during the disputed timeframe indicates that he was cooperative in treatment. He had failed prior treatment at the outpatient and partial hospitalization program levels of care. With regards to acceptance and engagement of the patient, the records support a score of 2. The patient participated in therapy actively, and his insight and judgment into his issues with his peer relationships appeared to improve as his treatment progressed. In terms of acceptance and engagement of the parents, the records support a score of 2. The parents worked actively and constructively with clinicians on a regular basis. Thus, the patient has a composite score of 16. This score correlates with outpatient services. Therefore, residential treatment services were not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the services at issue were 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.