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

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for residential treatment center substance abuse level of care.The submitted documentation does not support that residential treatment center substance abuse level of care was medically necessary. During the period in issue, the patient did not describe active suicidal ideation, and she showed cooperative behavior in treatment with no suicidal ideation or gestures. The progress notes indicate that the patient was open and honest in regards to her feelings about her mood, her feelings about her relationship with her family, and substance use. The patient did not display aggression towards peers or staff during the period in issue. While she continued to have some symptoms of mild depression, she was not experiencing any substance withdrawal, and the submitted documentation indicates a lack of medical problems. Additionally, she did not express any symptoms of psychosis.The American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) provides a reliable framework for determining the appropriate level of care for adolescents needing mental health treatment. In terms of risk of harm, the records support a score of 2. While the patient did have a history of suicidal ideation, during the period in issue the patient was not actively suicidal, and progress notes indicate that the patient was not engaging in self harm behaviors or expressing suicidal ideation. With regards to functional status, the records support a score of 2. The patient has had some issues with level of function, but the progress notes indicate significant improvement after a period of deterioration, as evidenced by appropriate activities of daily living and grooming as well as therapy participation. In terms of comorbidity, the records support a score of 2. The patient does not have active medical problems and reported a history substance use with several substances. While she did describe continued cravings at the beginning of treatment, there was no documentation of any withdrawal symptoms from any substances. With regards to level of stress of the recovery environment, the records support a score of 2. The patient was noted to have some interpersonal conflict with her family, however, progress notes document that her family therapy sessions were productive and not adversarial. In terms of level of support of the recovery environment, the records support a score of 2. The patients parents are involved in treatment on a regular basis and have the capacity to effect needed changes. 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 period in issue, and her presentation during the period in issue indicates that she was cooperative in treatment and any acute mental health symptoms that she had were resolved. In terms of acceptance and engagement of the patient, the records support a score of 2. The patient participates in therapy actively and is able to develop a positive relationship with clinicians. With regards to acceptance and engagement of the parent, the records support a score of 2. The patients parents worked actively and constructively with clinicians on a regular basis. Thus, the patient had a composite score of 17. This score correlates with intensive outpatient services. Therefore, residential treatment center services provided during the period in issue were not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested services 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 subspecialty 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.