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

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement for services received at Maple Lake Academy for treatment of the enrollees behavioral health conditions.  Findings:  The physician reviewer found that The physician reviewer found the Child and Adolescent Level of Care Utilization System (CALOCUS) 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 2. In July 2014, the patient put a knife to her mouth. Upon questioning, the patient claimed to have no intention of harming herself. With regards to functional status, the records support a score of 3. The patient had moderate functional impairment. The records document conflictual relationships with her peers and parents. She struggled with social interactions, which is a common symptom for patients with autism spectrum disorder. She has been described as controlling with friendships. In terms of comorbidity, the records support a score of 3. The patient had comorbidities of autism spectrum disorder and generalized anxiety disorder. She had no major medical problems and was described as healthy. With regards to environmental stress, the records support a score of 2. The patient had a mildly stressful environment. She had stress from expectations at home which were not being fulfilled. In terms of environmental support, the records support a score of 3. There was limited support in the environment. The patients parents appeared to have caregiver fatigue. In terms of resiliency, the records support a score of 3. The patient has had an equivocal response to treatment. She completed a wilderness therapy program prior to admission. It does not appear that this relieved the patients symptoms. With regards to acceptance and engagement, the records support a score of 3. Given the patients autism spectrum disorder, the patient has difficulty creating positive therapeutic relationships with clinicians and providers. She has difficulty collaborating in the development of a treatment plan. Therefore, the records support a composite score of 19. Based on these criteria, the patient met criteria for intensive outpatient program level of care and could have been treated in a less restrictive environment. The patient continued to need treatment for her autism spectrum disorder and generalized anxiety disorder, but this could have been accomplished in a less restrictive environment. Therefore, services received at Maple Lake Academy were not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the services at issue 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 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