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 residential treatment center services for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that to objectively determine the appropriate level of care for the patient, the case was examined using the Child and Adolescent Level of Care Utilization System (CALOCUS). This is an accepted, national standard for determining the appropriate level of care for children and adolescents. The patients risk of harm score is three (3), significant risk of harm. The patient has a history of chronic suicidal ideation and self-harm. The patient denied any suicidal ideation or homicidal ideation. The patient continued to have mood lability. The patient has a history of impulsive, self-harming behavior. The patients functional status score is three (3), moderate functional impairment. The patient has conflicted relationships with her peers and has chronic severe interpersonal deficits and struggles with the ability to engage in socially constructive activities. The patients co-morbidity score is three (3), significant co-morbidity. The patient has a co-morbidity of major depressive disorder and borderline personality disorder. The records do not show that the patient has a severe medical problem which requires 24-hour monitoring. The patients recovery environment stress score is three (3), moderately stressful environment. The patients environmental support score is two (2), supportive environment. It appears that the patient has a supportive parent. The patient was able to go a therapeutic pass with the patients parent without incident. The patients resiliency score is four (4), poor resiliency and response to treatment. Details of prior treatment is not known, but it appears that the patient has had poor response to prior treatment. However, notes state that the patient has been progressing well and the patient reported that her lithium and Lamictal were work. The patients acceptance and engagement score is two (2), constructive. The patient was participating in groups and therapy. The patient will passively cooperate with treatment planning and treatment. The patient will at times not participate in social activities due to aforementioned social deficits. Based on these criteria, the patient has a composite score of 20 and would meet criteria for a partial hospitalization program. The patient continued to need treatment for major depressive disorder and borderline personality disorder, but this could have been accomplished in a less restrictive environment. Therefore, RTC services provided were not medically necessary for treatment of the patients medical condition.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.