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

Nature of Statutory Criteria/ Case Summary:  The enrollees parent is requesting reimbursement for residential treatment center services. The enrollee was admitted for residential treatment services due to unstable mood, fluctuating energy level, acting out, and inability to attend school. Her treatment plan included individual psychotherapy two times per week, family psychotherapy once per week, group psychotherapy and psycho-education two to three times per day, nutrition consultation one to two times per week, physician consultation one to two times per week and psychiatric consultation once per week. Intake documentation describes the enrollee as disheveled, alert and oriented; with an anxious mood, cooperative behavior, and poor insight. The enrollee reported a history of visual and auditory hallucinations and reported she was experiencing these during the intake interview. The enrollee endorsed symptoms of poor concentration, indecisiveness, obsessions, compulsions, risk-taking, confusion, manipulating, dishonesty, lying, and stealing. Utilizing the CALOCUS system to assess appropriate level of care, for risk of harm, the enrollees score is 3, due to no active suicidal or homicidal ideation, but extreme distress and/or a history of suicidal/homicidal behavior. For functional status, the enrollees score is 3, due to the enrollee being conflicted, withdrawn, or otherwise troubled in relationship with peers, adults and/or family, but without episodes of physical aggression. For comorbidity, the enrollees score is 2, due to self-limiting medical conditions present that are not immediately threatening or debilitating, do not impact the presenting condition and are not affected by it. For recovery environment level of stress, the enrollees score is 2, due to expectations for performance at home and school that create discomfort. For recovery environment level of support, the enrollees score is 2, due to the presence of family/primary caretakers who are willing and able to participate in treatment if requested to do so and have the capacity to effect needed changes. For treatment and recovery history, the enrollees score is 3, as the enrollee has demonstrated an inconsistent or equivocal capacity to deal with stressors and maintain normal development. Previous experience in treatment at a low level of intensity has not been successful in relief of symptoms or optimal control of symptoms. For engagement and recovery status, the enrollees score is 2, as the enrollee positively cooperates in treatment planning and treatment. The enrollee is able to develop a trusting, positive relationship with clinicians and other care providers. The enrollees composite CALOCUS score is 17, which correlates with an intensive outpatient level of service. Medical evidence does not support the services at issue in this clinical setting.Final Result: The reviewer determined that the requested services were not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in psychiatry and 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 similar medical condition