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 Services at a facility that offers and utilizes Cognitive Behavioral Therapy (CBT), Dialectical Behavioral Therapy (DBT), Eye Movement Desensitization and Reprocessing (EMDR), and medication management/psychiatry, for up to 6 months with the possibility of up to 12 months that can accommodate special education needs and that is appropriately qualified to treat autism and the enrollees other conditions.At issue in this case is whether any or all of the requested Residential Treatment Center Services at a facility that offers and utilizes Cognitive Behavioral Therapy (CBT), Dialectical Behavioral Therapy (DBT), Eye Movement Desensitization and Reprocessing (EMDR), and medication management/psychiatry, for up to 6 months with the possibility of up to 12 months that can accommodate special education needs and that is appropriately qualified to treat autism and the patients other conditions are medically necessary as defined in Health and Safety Code section 1374.72(a)(3)(A). Medically necessary treatment of a mental health or substance use disorder is defined in Health and Safety Code section 1374.72(a)(3)(A) as follows:(A) For purposes of this section, Medically necessary treatment of a mental health or substance use disorder means a service or product addressing the specific needs of that patient, for the purpose of preventing, diagnosing, or treating an illness, injury, condition, or its symptoms, including minimizing the progression of that illness, injury, condition, or its symptoms, in a manner that is all of the following:(i) In accordance with the generally accepted standards of mental health and substance use disorder care.(ii) Clinically appropriate in terms of type, frequency, extent, site, and duration.(iii) Not primarily for the economic benefit of the health care service plan and subscribers or for the convenience of the patient, treating physician, or other health care provider.The American Academy of Child and Adolescent Psychiatry (AACAP) and American Association for Community Psychiatry (AACP) have unified the Child and Adolescent Level of Care Utilization System (CALOCUS) and the Child and Adolescent Service Intensity Instrument (CASII) into a single instrument, the Child and Adolescent Level of Care/Service Intensity Utilization System (CALOCUS-CASII). The six dimensions include: (1) risk of harm; (2) functional status; (3) co-occurrence of developmental, medical, substance use and psychiatric conditions; (4) recovery environment (a. stressors and b. supports); (5) resiliency and response to services; and (6) engagement. The composite score is then used to determine the level of care needed.With regard to risk of harm, the records support a score of 4, which corresponds with serious risk of harm. The patient is reported to have tried to choke his brother and also harmed himself (biting, head banging). The patient does not meet criteria for a score of 5, extreme risk of harm, however, as his behavior appears to be reactive and impulsive rather than planned. Although police had been called multiple times, he had no history of prior inpatient hospitalizations.In terms of functional status, the records support a score of 4, which corresponds with serious functional impairment. This dimension assesses the degree to which a person is able to fulfill responsibilities within developmental constraints. In this instance, the patient has had a deterioration of interactions with family members that has resulted in impulsive outbursts involving aggression, property destruction, and self-harm.With regard to co-occurrence of developmental, medical, substance use and psychiatric conditions, the records support a score of 3, which corresponds with significant co-occurrence.  In terms of level of stress of the recovery environment, the records support a score of 3, which corresponds with a moderately stressful environment.  With regard to level of support of the recovery environment, the records support a score of 2, which corresponds with a supportive environment.  In terms of resiliency and response to services, the records support a score of 4, which corresponds with poor resiliency and/or response to services. With regard to engagement, the records support a score of 4, which corresponds with minimal engagement. These findings give the patient a composite score of 24, which is consistent with Level 5 Medically Monitored Intensive Integrated Services: Non-Secure, 24-hour Services with Psychiatric Monitoring. This is consistent with the level of care the patient is currently receiving. The patient has demonstrated risky behaviors that require residential treatment. As this is his first experience with residential care, it is not possible to predict in advance how many months of care he will need. Placement in a shorter-term residential facility is clinically appropriate and consistent with CALOCUS/CASII guidelines. Furthermore, the specific modalities of treatment should be determined by the treatment team. While the patients parent has requested that the residential treatment center offer and utilize Cognitive Behavioral Therapy (CBT), Dialectical Behavioral Therapy (DBT), and Eye Movement Desensitization and Reprocessing (EMDR), these therapies can be provided on an outpatient basis as well as in a residential treatment setting. In addition, the patient has been deemed ineligible for an IEP by his school district and was receiving only 504 accommodations prior to his residential placement, so special education services are also not medically necessary at this time.Accordingly, the requested Residential Treatment Center Services at a facility that offers and utilizes Cognitive Behavioral Therapy (CBT), Dialectical Behavioral Therapy (DBT), Eye Movement Desensitization and Reprocessing (EMDR), and medication management/psychiatry, for up to 6 months with the possibility of up to 12 months that can accommodate special education needs and that is appropriately qualified to treat autism and the patients other conditions are not medically necessary as defined in Health and Safety Code section 1374.72(a)(3)(A).Final Result: The reviewer determined that the requested services are not medically necessary as defined in Health and Safety Code section 1374.72(a)(3)(A). 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.