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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for residential treatment center services for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that 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. As of the date in dispute, the patients risk of harm score is three (3), serious risk of harm. The patient has a history of self-harming behavior of cutting self. The records submitted do not document a history of suicide attempts. The patient has intermittent passive thoughts of suicide and self-harm but did not have any acute suicidal ideation on the date in dispute. The patients functional status score is three (3), moderate functional impairment. The patient struggles with social situations which is a main feature of autism spectrum disorder. The patient struggles in school due to inability to focus but is able to perform adequately when directed. The patients co-morbidity score is three (3), significant co-morbidity. The patient has a co-morbidity of autism spectrum disorder, ADHD, major depressive disorder, and persistent motor tic disorder. The patient does not use illicit substances. The patient did not have any medical problems which required 24-hour monitoring. The patients recovery environmental stress score is three (3), moderately stressful environment. The patient has a history of being verbally and physically abusive. This causes interpersonal conflicts in the family. However, per documentation, the patient has had a better relationship with the parent for the last five months prior to admission. The patients environmental support score is three (3), limited supportive environment. The patients parent is supportive. The patients resiliency score is two (2), positive response to treatment. The patient has made improvements since care begun. The patient was doing well for the last week. There were no changes to the patients medications. There were no violent outbursts. This appears to be an improvement from the patient that had previously assaulted and broken the collarbone of another resident many months prior in a different facility. The patient continues to struggle with social situations. Given the diagnosis of autism spectrum disorder, it is likely that the patient will continue to struggle with social situations. The patients acceptance and engagement score is three (3), obstructive. The patient is ambivalent with providers. The patient does not agree with rules, but will obey begrudgingly. The patient continues to struggle with accepting responsibility for his actions. Based on these criteria, the patient has a composite score of 20 and meets the criteria for a partial hospitalization program (PHP). Thus, the patient could have been treated in a less restrictive environment. Although the patient continued to need treatment for autism spectrum disorder, ADHD, major depressive disorder, and persistent motor tic disorder, this could have been accomplished in a less restrictive environment. 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. proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.