Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement for inpatient behavioral health services provided for treatment of the enrollees behavioral health conditions. Findings:  The physician reviewer found that this patient was initially admitted to the acute inpatient setting due to aggressive behaviors towards peers.  He was not placed on any psychotropic medication during his stay.  The patient was noted to be cooperative in therapy most of the time.  The progress notes do not indicate aggression towards peers or staff.  The progress notes do not note self-harm behaviors or active suicidal or homicidal ideation.  The progress notes do not document signs or symptoms of psychosis or serious problems with activities of daily living. Effective treatment of pediatric bipolar disorder can occur in a setting less restrictive than inpatient and often occurs on an outpatient basis after a patient no longer shows any dangerous behavior, as was the case for this patient. In cases such as this, an evidence-based instrument such as the Child and Adolescent Level of Care Utilization System (CALOCUS) is indispensable in determining necessary level of care for children. In terms of risk of harm, the records support a score of 2.  The patient had a history of aggression.  However, the patient was not having active suicidal ideation or harming himself or others. With regards to functional status, the records support a score of 2 or 3.  The patient had issues with role performance at school due to psychiatric symptoms. With regards to medical, addictive and psychiatric comorbidity, the records support a score of 1.  The documentation supports overall medical stability and no substance abuse issues. In terms of recovery environment level of stress, the records support a score of 2.  The patient has a stable living environment. With regards to environment support, the records support a score of 2.  The patients family is supportive of his treatment needs.  In terms of resiliency and treatment history, the records support a score of 3.  The patient had minimal to moderate treatment response overall as judged by repeated hospitalizations and a previous residential treatment stay. With regards to acceptance and engagement of the patient, the records support a score of 2. In terms of acceptance and engagement of parents, the records support a score of 2.  The patients family participated in his therapy.  Thus, the patient has a composite score of 16 or 17. A score of 17 correlates with intensive outpatient services.  Thus, there is a lack of support for inpatient behavioral health level of care in this clinical setting. All told, inpatient behavioral health services provided were 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.