Appeal type: Medical Necessity
Decision: Upheld

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 does not have a history of suicide attempts. The patient does have intermittent suicidal ideation with no plan. The patient reports that the patient fears death. The patient does have a history of cutting behavior which started in August 2015. The patients functional status scores is three (3), moderate functional impairment. The patient has conflicted relationships with peers. The patient has a history of being bullied and will isolate from friends. The patient was suspended from school in April 2016 after threatening suicide to a peer if the peer did not respond back to a text. The patient has supportive parents but does have conflicts with parents. The patients co-morbidity score is three (3), significant co-morbidity. The patient has a co-morbidity of major depressive disorder, anxiety disorder, ADHD, and neurodevelopmental disorder. The patient does not have any medical problems which require 24-hour monitoring. The patients recovery environmental stress score is three (3), moderately stressful environment. The patient finds social milieu to be stressful and has difficulty making and keep social relationships. The patient also has expectations for performance at school and family life which create discomfort if not met. The patients environmental support score is two (2), supportive environment. The patients parents are supportive of the patient. The patients resiliency score is three (3), equivocal resiliency and response to treatment. The patient has had outpatient treatment previously with an equivocal response. There have been periods of improvement followed by relapse. The patients acceptance and engagement score is two (2), constructive. The patient is cooperative and friendly with staff. The patient is accepting of treatment recommendations. Based on these criteria, the patient has a composite score of 19 and meets the criteria for intensive outpatient program treatment. Thus, the patient could have been treated in a less restrictive environment. The patient continued to need treatment for depression, anxiety, and neurodevelopmental disorder, but this could have been done in 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.