Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment. The patient was admitted to the residential treatment center in early November 2016. The patient had engaged in 14 months of treatment in the residential treatment center prior to the disputed timeframe. During the disputed timeframe, the patient showed cooperative behavior and treatment progress. The patient was not displaying signs of psychosis. The records noted that the patient followed treatment programming as instructed. The patient attended regular individual and group therapy as well as family therapy sessions. The provider indicated that the patient was not having medication side effects and was not experiencing psychosis, suicidal ideation, or homicidal ideation. The patient did not display aggression towards peers or staff during the disputed timeframe. The patients family was actively involved with treatment, including off campus passes as well as family therapy sessions. The records did not document severe mood or anxiety symptoms or serious behavioral issues.  In cases such as this, an evidence-based instrument such as American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) assists in determining the necessary level of care for children. In terms of risk of harm, the records support a score of 1. The medical records indicated that the patient was not actively or passively suicidal. With regards to functional status, the records support a score of 2. The patient had some issues with level of function due to mental illness and relational issues, but overall showed appropriate daily functioning while in treatment. In terms of comorbidity, the records support a score of 1. The patient did not have a history of past medical issues, and the records did not document issues with substance abuse. With regards to level of stress of the recovery environment, the records support a score of 2. The patient was noted to have interpersonal conflict with the family members in the past. However, the progress notes document that the patients family sessions were productive and were not adversarial. In terms of level of support of the recovery environment, the records support a score of 2. The patients family was involved in treatment on a regular basis. With regards to resiliency and treatment history, the records support a score of 2. The records indicate that the patient had an excellent response to the initial 14 months of residential treatment. In terms of acceptance and engagement of the patient, the records support a score of 2. The patient actively participated in therapy. With regards to acceptance and engagement of the parent, the records support a score of 2. The patients parent worked actively and constructively with clinicians on a regular basis. Therefore, the patient has a composite score of 14. This score correlates with outpatient services. Thus, residential treatment was not medically necessary for the treatment of this patient.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 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.