Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A 20-year-old female enrollee has requested reimbursement for residential treatment center (RTC) 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), serious risk of harm. The patient had a suicide attempt prior to admission after overdosing on medications. She has a history of overdosing on Xanax and dextromethorphan. At the time of admission, the patient did not have any suicidal ideation or homicidal ideation. She did not have any psychosis. The patient has a history of cutting since age eight. The patients functional status score is three (3), moderate functional impairment. The patient attempted to attend her first year of college but returned home due to depression. The patient has chronic, severe deficits in interpersonal relationships and she does not have the ability to maintain responsibilities. The patients co-morbidity score is three (3), significant co-morbidity. The patient has a co-morbidity of major depressive disorder and substance use disorders. The patient did not have any medical problems, which required 24-hour monitoring. The patients recovery environment stress score is three (3), moderately stressful environment. The patient had a fight with her boyfriend 1.5 months prior to admission to the RTC, which pre-empted her suicide attempt. The patients parents were divorcing. The patients environmental support score is two (2), supportive environment. The patient has supportive parents who are willing to participate in treatment. The patients resiliency score is three (3), equivocal response to treatment. The patient has had two prior psychiatric hospitalizations and outpatient treatment. The patient continued to have depressive episodes with impulsive behaviors. The patients acceptance and engagement score is two (2), constructive. The patient was engaged in treatment and was cooperative with care. Based on these criteria, the patient has a composite score of 19 and met criteria for treatment at the intensive outpatient program (IOP) level of care. Thus, the patient could have been treated in a less restrictive environment. The patient required treatment for her major depressive disorder and substance use, but this could have been accomplished at a less restrictive environment. Therefore, the 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.