Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 


The parent of a 15-year-old female enrollee has requested reimbursement for mental health residential treatment provided from 12/24/15 through 4/08/16.  The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health conditions.  The physician reviewer found that in order to objectively determine the appropriate level of care for the patient, the case was examined using the Child and Adolescent Level of Care Utilization System (CALOCUS). This is an accepted, national standard for determining the appropriate level of care for children and adolescents. In terms of risk of harm, the patient scored 2. She demonstrated some risk of harm.  She denied any suicidal ideation or homicidal ideation at the time of admission. However, her mother reported that the patient would have mild suicidal ideation with no intent or conscious plan.  In terms of functional status, the patient scored 3.  The records noted moderate functional impairment.  There had been conflicts in the family over the patients new boyfriend. She reported some interpersonal conflicts with friends.  Regarding comorbidity, the patient scored 3.  The patient had a comorbidity of major depressive disorder, emotional dysregulation, and possibly abusing inhalants. The patients mother reports that she is using inhalants, but the patient denied this allegation. The patient was also sexual and physically assaulted by a boyfriend six month previous to being admitted. In terms of her recovery environment and environmental stress, she scored 3. The patients mother is supportive of the patient. However, there is significant conflict over the patient being able to see her boyfriend. This is in part of what led to the patient requiring intensive treatment.  In terms of environmental support, the records support a score of 2.  The patient has supportive mother who was trying to help the patient. In general, other than sensitive topics, the patient and her mother have a good relationship. The family was willing to participate in treatment if requested. Regarding resiliency and treatment, the records support a score of 3.  The patient has had prior treatment, but continued to have emotional dysregulation. The patient requires strong professional support to maintain recovery and emotional balance. Regarding acceptance and engagement, the patient scored 2. Per the records, she was able to develop positive relationships with clinicians and care providers. She was cooperative with staff and followed instruction. Thus, this patient has a composite score of 18.  Based on these criteria, the patient continued to require treatment for her depression and mood dysregulation, but she could have been treated in a less restrictive environment in an intensive outpatient program. It is standard of care that patients be treated in the least restrictive environment possible. The current medical evidence does not support the services at issue in this clinical setting.  All told, mental health residential treatment provided from 12/24/15 through 4/08/16 was not medically necessary for the treatment of this patient.  Therefore, the services at issue were not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.