Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 


The parent of a 16-year-old male enrollee has requested reimbursement and prospective authorization and coverage for eating disorder residential treatment center services provided from 2/14/17 forward. The Health Plan has denied this request indicating that the services at issue were not and are not medically necessary for treatment of the enrollees behavioral health condition. The physician reviewer found that the eating disorder residential treatment center services provided from 2/14/17 forward were not and are not medically necessary for treatment of the patients medical condition. According to the documentation submitted for review, the patient was cooperative in treatment. The patient was noted to struggle with acceptance of his eating disorder on numerous occasions. However, he was insightful into coping skills needed to manage his condition. On 2/12/17, the patient was noted to eat 100% of his meals. In addition, the patient was cooperative with staff and his activities of daily living appeared intact. The medical records do not support active suicidal ideation or psychosis during the disputed period. Moreover, the records do not indicate that he had failed intensive outpatient services of any type prior to admission to residential treatment. There were no significant or severe behavioral problems noted during his stay. Although continued treatment is indicated to further improve upon his coping skills, anxiety management, social functioning, mood issues, and eating disorder treatment, the patient does not require the restrictiveness of a residential treatment facility to receive his care. The treatment goals listed could have been accomplished on an outpatient basis. Based on the documentation, the patient has stabilized sufficiently to allow transition to a less restrictive setting. Per the Child and Adolescent Level of Care Utilization System (CALOCUS), the patient has a score of 15 to 17, which 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 during the period under dispute at the residential level of care. According to the documentation submitted for review, the patient had no risk of harm. His functional status was mild to moderate, as he is able to complete activities of daily living in an age appropriate manner. He has no co-morbidities, he does not have active serious medical problems or substance issues. His recovery environment and level of stress is mild. Although the patient has issues with family relationships, he has a stable housing situation and supportive family who is actively involved in treatment and attends family therapy sessions on a regular basis. His resiliency and treatment history is moderate due to positive treatment response in the past several weeks and no history of any failed treatments or any types of tried or failed outpatient treatment. The patient participates actively in therapy, but has poor insight. His parents acceptance and engagement is constructive given that they have actively worked with his providers. For the reasons provided, the services at issue were not and are not medically necessary for treatment of the patients medical condition. Therefore, the services at issue were not and are not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.