Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 


The parent of a 17-year-old female enrollee has requested reimbursement for residential treatment services provided from 8/26/15 through 12/31/16. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health condition. The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity for the services at issue in this clinical setting. The Child and Adolescent Level of Care Utilization System (CALOCUS) is an accepted national standard for determining the appropriate level of care for children and adolescents. According to the CALOCUS criteria, this patients risk of harm is scored as a 3, significant risk of harm. The patient has a history of cutting, but she has not had any cutting since ninth grade. The parent had reported that the patient has had prior suicide attempts. The patient had been researching on the internet about suicide and wrote a suicide poem in January 2015. However, the RTC provider noted that she started having suicidal ideation in the 8th grade with the last reported suicidal ideation some time last year. It does not appear that she had presented suicidal ideations while at RTC. The patients functional status is scored a 3, moderate functional impairment. The patient graduated from a school that required accommodations due to learning impairments. The patient has some conflictual relationships with her family but is able to engage in interpersonal relationships. Recent gains in functioning have been achieved while participating in a structured setting. Her co-morbidity is assessed at a 3, significant co-morbidity. The patient has a co-morbidity of bipolar disorder, ADHD, learning disabilities, and emotional lability. Her environmental stress is scored a 3, moderately stressful environment. The patient has previously had frequent interpersonal conflicts with her parents. The patient has had prior physical altercations with her parents and have threatened to hurt her twin sister when she was younger.  Her environmental support is a 2, supportive environment. The patient has supportive parents who are willing to participate in treatment if asked to do so.  Her resiliency is scored a 2, positive response to treatment.  The patient has documented improvement with the treatment she received at the wilderness program. Her acceptance and engagement is scored a 2, constructive. The patient is cooperative with treatment. The patient is able to develop a positive relationship with clinicians and care providers. At admission, the patient denied any suicidal or homicidal ideation. The patient reports that her mood had improved since discharging from the wilderness program. The provider felt that the patient was manic because the patient had rapid speech and grandiosity, but then stated that her mania was chronic and not cyclical suggesting it was tied with cognitive processing or personality development. It is noted that the patient was sleeping well and most notes document that the patient will speak rapidly. The provider reports that she her use of rapid speech as a way to accommodate deficits in her auditory memory. It appears there was uncertainty whether the patient was acutely manic at the time of admission or if this was the patients baseline way of communicating. This patients composite score using the CALOCUS criteria is 18.
Based on these criteria, the patient would have met criteria for a less restrictive program like an intensive outpatient program (IOP). The patient had shown significant improvement since being discharged from the wilderness program. The records do not support an admission to a RTC level of treatment nor did the records support the length of treatment at a highly restrictive environment from 8/26/15-12/31/16. While this patient required treatment for her bipolar disorder and ADHD, this could have been provided in a less restrictive environment. Accordingly, the residential treatment services provided from 8/26/15 through 12/31/16 were not medically necessary. Therefore, for the reasons stated above, the services at issue were not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.