Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for residential treatment center services provided for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that the RTC services provided were not and are not medically necessary for treatment of the patients medical condition. 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 (3), a significant risk of harm. The patient has a history of prior suicide attempts. The patient admitted to suicidal thoughts with a future plan to overdose on Benadryl. She denied any current suicidal ideation and stated that she would not overdose at the RTC but explained to the therapist that she was cheeking medications to save up enough medications to overdose at an unspecified later time. The patients functional status score is (3), moderate functional impairment. The patient has a conflictual relationship with her parents. She is socially isolative and describes that she hates all people. She has chronic severe deficits in interpersonal relationships and the ability to maintain responsibilities. Per documentation, she has not had any episode of physical aggression with parents or peers. The patients co-morbidity score is (3), significant co-morbidity. The patient has a history of major depressive disorder and bulimia nervosa. She abuses Adderall to suppress her appetite. She does not have any current medical problems that require 24-hour supervision. In terms of her recovery environment, she has an environmental stress score of (3), moderately stressful environment. The patient feels that her family environment is chaotic and stressful. However, both parents appear motivated to help the patient. Her environmental support score is (3), limited support in environment. The patient has mixed emotions about her parents. However, her parents are participating in treatment. She has a resiliency score of (4), poor resiliency and response to treatment. The patient has limited insight into her condition. She does not feel that she has an eating disorder. She reports that she plans to continue to purge when released from the RTC. She has difficulty in transitions in changes to her routine. Her acceptance and engagement score is (3), obstructive. The patient minimizes her current eating disorder problems and does not have the desire to change her behaviors and openly admits that she is going to purge after therapy sessions. She minimizes the consequences of her eating disorder. She is ambivalent in her relationships with clinicians and care providers. The patients composite score is 22. Based on these criteria, the patient would meet criteria for a partial hospitalization program (PHP) and could be treated in a less restrictive environment. Continued therapy is clinically indicated to treat her depression and eating disorder, but this could be performed at a lower level of care. Therefore, the services at issue were not and are not medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the services at issue were not and are 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.