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

Nature of Statutory Criteria/Case Summary: The parent of a 13-year-old male enrollee has requested reimbursement and prospective authorization and coverage for residential treatment care for treatment of the enrollees behavioral health condition. Fulfills requirements of (1374.33) (h)(1)(A), (B), and (C).Findings:  The physician reviewer found that there is a lack of support in the medical literature for the services at issue. Overall, it appears that most of this patients functional issues were due to his impulsive behaviors and substance use. Based on the records, the RTC admission was due to his oppositional defiant disorder (ODD) diagnosis.   The evidence based literature regarding childrens mental health treatment has shown that treatment outside of a residential setting is effective and appropriate and is  as beneficial as RTC programs. Barth and colleagues noted in their review, children in intensive in-home therapy were more likely in the future to live with family, make progress in school, not have trouble with the law, and have better placement permanence than youth in residential treatment.  A recent article by Preyde and colleagues noted the following, Residential treatment is best when it involves the family in the treatment process, promotes collaboration with community treatment for discharge, and is shorter in duration. This patients treatment prior to his admission to RTC was vague per the records. It appears that he refused treatment on several occasions. The records do not indicate that the patient obtained treatment in an intensive outpatient level of care or a partial hospital program level of care, or intensive in-home treatment. There are studies that indicate that gains made during a stay in RTC may not transfer well in the youths natural environment, which often creates a cycle where children are often repeatedly readmitted.  In cases such as this, an evidence based instrument such as the CALOCUS is indispensable in determining necessary level of care for children, to insure their level of care meets their individual needs at the least restrictive setting possible. Using the CALOCUS criteria, this patients risk of harm is scored a 2. He has a history of impulsive actions. However, the medical records indicate that the patient was not actively suicidal and was not participating in any self harm behaviors while at the RTC. The patients functional status is between 2-3. The patient has had school disruption but was able to complete his activities of daily living in an age appropriate manner. His co-morbidity is scored a 2, mild. This patient did not have active serious medical problems but has a substance use history. His recovery environment, is scored a 2, the patient has a positive recovery environment and a stable housing situation despite strained relationships and his recurrent behavioral issues. The patients recovery environment is scored a 2. The patients family is involved in treatment and is supportive. The patients resiliency and treatment history is moderate/equivocal and is scored a 3. The records do not show a clear response to treatment due to minimal treatment or no intensive treatment in the recent past. His acceptance and engagement, child/adolescent is constructive and is scored a 2. The patient participates in therapy and has used coping skills learned in therapy per the records. The patients acceptance and engagement is constructive and is scored a 2. The records report that his parents work actively and constructively with clinicians. According to the LOCUS criteria, this gives the patients presentation a composite score of 17-18.  As such, this patients score correlates with a treatment at an intensive outpatient services and not at an RTC.  According to the LOCUS criteria, the patient would need to have a score of 23-28 in order to be treated at an RTC. Therefore, RTC services forward were not and are not medically necessary for treatment of this patient. Fulfills requirements of (1374.33)(h)(1)(H) and (K)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. Fulfills requirement of 1374.33(h)(1)(I)Credentials/Qualifications: The reviewer is board certified in psychiatry with sub-specialty 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. Fulfills requirement of (1374.33)(h)(1)(G)