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

Nature of Statutory Criteria/Case Summary: The parent of a transgender female-to-male patient has requested authorization and coverage for residential treatment center services going forward. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees major depressive disorder; generalized anxiety disorder; feeding or eating disorder; and post-traumatic stress disorder.At issue in this case is whether the requested residential treatment center services going forward are medically necessary for treatment of the patients behavioral health condition.This appeal concerns denial of stay at the residential treatment center (RTC). During the disputed timeframe, the beneficiary showed cooperative behavior and treatment progress. At times, he struggled with urges to self-harm but was able to speak with staff about these urges and find resolution. It is noted that the patient has been engaging in intermittent self-harm for approximately three years. It appears to be a chronic issue that is unlikely to resolve at the residential treatment center.The notes indicate that he had intermittent issues with peers as he was teased at times. He followed all treatment programming as he was instructed. The progress notes indicate that he was open and honest in regards to his feelings about his self-harm, mood, family relationships and other problematic issues. He did not have active suicidal or homicidal ideation, and the psychiatrist recently rated his suicide risk as low.The patient did not display aggression towards peers or staff during the disputed period. His family was involved with treatment and appeared to understand the patients needs as referenced by the progress notes, which indicate their ability to aid with emotional support. The patient did report some more recent symptoms of hallucinations that were not likely due to a psychotic or thought disorder illness. The CALOCUS scoring as below for the disputed period as assessed by the patients symptoms:1) Risk of harm--- some (2), the medical records indicate that the patient was not actively suicidal at any time but had a history of suicidal ideation recently. 2) Functional status--- mild(2), the patient has had some issues with level of function due to chronic mental illness; but overall showed appropriate daily functioning including school progress in treatment and prior to treatment at the RTC.3) Co-Morbidity---minor (2), the patient does not have active medical problems and has a history of cannabis use with last use three months prior to admission.4A) Recovery environment, level of stress---mild (2), the patient was noted to have mild interpersonal conflict with peers due to gender dysphoria and sexual orientation. He also had interpersonal conflict with family members due to his behaviors. However, the progress notes document that his relationship and family sessions were productive and were not adversarial. 4B) Recovery environment, level of supportsupportive (2), the patients parents are involved in treatment on a regular basis and appear to understand his needs.5) Resiliency and Treatment historymoderate/equivocal (3), it appears that the patient has had response to a short period in the RTC. He was participating in therapy programming and was not displaying any seriously disruptive behaviors.6A) Acceptance and engagement, child/adolescent---constructive (2), the patient participates in therapy actively and he was cooperative with consistent engagement and no apparent disruptive behavioral issues while in treatment. The progress notes indicate that the patient engages in his treatment team in times of stress in order to work through problematic issues.6B) Acceptance and Engagement, Parent ---constructive (2), the parents work actively and constructively with clinicians on a regular basis. This gives the beneficiarys presentation a composite score of 17. This score correlates with a treatment intensity level of three which correlates with Intensive Outpatient Services.` This score is judged by the acuity of the patients symptoms and environment at the date of going forward. According to the CALOCUS, the beneficiary would need to have a score of 23-28 in order to require treatment in a residential treatment center. Therefore, the requested services are not medically necessary. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients behavioral health 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.