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 center services. The submitted documentation fails to demonstrate the medical necessity of the services at issue. There was no indication that she was aggressive with peers. She engaged in some self-harm type behaviors that including scratching on herself. There was no indication of suicide attempts. The records did not document severe psychiatric symptoms such as mania or psychosis. She was not expressing any suicidal or homicidal ideation. It is not clear that less restrictive resources were not available or not appropriate for the patients needs. The progress notes did not document that the patient was receiving intensive treatment prior to her residential treatment admission. The records do not indicate that the family has tried functional family therapy (FFT) which is an evidence-based treatment for the patients condition. The patient was not experiencing substance withdrawals at the time of admission. 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 cutting behaviors. The patient was not having active suicidal ideation or other behaviors or thoughts that would warrant a higher score in this category. With regards to functional status, the records support a score of 3. The patient has had minimal disruption and was able to complete activities of daily living in an age appropriate manner while at the treatment center. In terms of comorbidity, the records support a score of 1. The patient does not have active serious medical problems or substance use noted. With regards to level of stress of the recovery environment, the records support a score of 2. The patient had issues with family relationships, but had 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 attend family therapy sessions on a regular basis. With regards to resiliency and treatment history, the records support a score of 3 due to equivocal treatment response in the past, taking into account the fact that the patient had minimal treatment documented in the records. In terms of acceptance and engagement, of the patient, the records support a score of 3. The patient participates in therapy, but is reluctant. With regards to acceptance and engagement of the parent, the records support a score of 2. The parents work actively and constructively with clinicians. Thus, the patient has a composite score of 18.  The score correlates with intensive outpatient services. Thus, this patients presentation and symptoms did not require residential treatment. Therefore, residential treatment center 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.