Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 


The parent of a 14-year-old male enrollee has requested reimbursement for residential mental health treatment center services provided from 9/27/16 through 11/22/16. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health condition. The physician reviewer found the RTC services provided from 9/27/16 through 11/22/16 were not medically necessary for treatment of the patients medical condition. According to the documentation submitted for review, the patient was cooperative with staff and his activities of daily living were intact. The medical records do not support active suicidal ideation or psychosis during the disputed period. There were no significant or severe behavioral problems noted during his stay and his mood was noted to be frequently euthymic. The records document that at times he was noted to be depressed and tearful. The patient reported that he was able to use coping skills that he learned in therapy to deal with conflict with peers and emotional struggles. The patient was receiving DBT at the residential treatment center. DBT is routinely provided on an outpatient basis providing that a patient is safe to participate in this type of therapy in that setting. In this case, the patient could have been treated with DBT therapy on an outpatient basis due to his cooperation level and lack of safety concerns. The patients acute psychiatric symptoms had improved during the first several weeks of his treatment. He was benefiting from individual and group therapy and, due to his participation level, insight and lack of dangerous behaviors could then have transitioned to a lower level of care. Based on the Child and Adolescent Level of Care Utilization System (CALOCUS), the patient scored a composite score of 17, which correlates with a treatment intensity level of three (3) which correlates with intensive outpatient services. This score is judged by the acuity of the patients symptoms and environment during the period under dispute at the RTC. The patients risk of harm was at two (2) due to his history of suicidal ideation.   However, the medical records indicate the suicidal ideation was more passive in nature and not active ideation. During the disputed period he was not experiencing self-harm behaviors. His functional status was moderate at three (3), as he had some school disruption and is able to complete his activities in daily living in an age appropriate manner. His co-morbidity is one (1), the patient does not have active serious medical problems or any substance use diagnosis. His recovery environment is mild at two (2), the patient has a positive recovery environment and a stable housing situation. His recovery environment level of support is supportive at two (2). His family is actively involved in treatment and attend family therapy sessions on a regular basis, the patient reported that his family visits were positive and he looked forward to them. His resiliency and treatment history scored at three (3) due to positive treatment response in the recent past. His acceptance and engagement, was constructive at two (2), the patient actively participated in therapy and has used coping skills learned in therapy on numerous occasions His parents acceptance and engagement was also at two (2), the parents work actively and constructively with clinicians. According to the CALOCUS the beneficiary would need to have a score of 23-28 in order to require treatment in an RTC. Therefore, the services at issue were not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.