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 services for treatment of the enrollees behavioral health conditions. Findings:  The physician reviewer found that that in order to objectively determine the appropriate level of care for this patient, the Child and Adolescent Level of Care Utilization System (CALOCUS) was utilized. This is an accepted, national standard for determining the appropriate level of care for children and adolescents. In terms of risk of harm, the records support a score of 3. The patient had a suicide attempt several months ago with an attempt to overdose on Advil. However, around the first date of service in dispute, the patient did not have any suicidal ideation, homicidal ideation, psychosis, or hallucinations. With regards to functional status, the records support a score of 3. The patient has above average intelligence, but had started putting very little effort into her school work. She has a history of intentional truancy and using alcohol and marijuana. In terms of comorbidity, the records support a score of 3. This patient has comorbidities of attention deficit/hyperactivity disorder, major depressive disorder with psychotic features, alcohol use disorder, and cannabis use disorder. However, the patient did not have any medical problems which required 24-hour monitoring.  With regards to environmental stress, the records support a score of 2. The patient has a mildly stressful environment. She has a supportive family and gets along with her family. Expectations for performance at home and in school work do create discomfort. In terms of environmental support, the records support a score of 2. The patient has supportive parents who are willing to participate in treatment if asked to do so. With regards to resiliency, the records support a score of 2. Prior to the suicide attempt, the patient had minimal treatment. It appears that the patient has made improvements from treatment. In terms of acceptance and engagement, the records support a score of 2. The patient has been cooperative with staff for the majority of time. At times, the patient will refuse to participate in therapy. She will passively cooperate in treatment planning and treatment. Therefore, the records support a composite score of 17. Based on these criteria, the patient would meet criteria for an intensive outpatient program and could be treated in a less restrictive environment. The patient had made improvements in her residential treatment. The patient continued to need treatment for her attention deficit/hyperactivity disorder, major depressive disorder with psychotic features, alcohol use disorder, and cannabis use disorder, but she could have been treated safely and effectively in a less restrictive environment. All told, residential treatment 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 expertise 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.