Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of a 16-year-old transgender female enrollee has requested reimbursement for residential treatment services provided. Findings:  The physician reviewer found that The documentation submitted does not support the medically necessity for the services at issue in this clinical setting. The submitted documentation indicates the patient was struggling with interpersonal issues along with gender dysphoria. The medical records do not support active suicidal ideation or psychosis during the several weeks after the patient was admitted to the residential treatment center or during the disputed period. The records indicate the patient was open in individual and group therapy sessions throughout the stay. There were no significant or severe behavioral problems noted. The patient presented as happy and she occupied herself during her free time by listening to music. She was noted to be able to manage herself appropriately. The patient was able to complete activities of daily living without complications. She was off campus for the entire day. The patient had a psychiatric follow-up. At this appointment, she reported that she was less anxious and did not desire any medication changes. The report noted the patient was not experiencing any psychosis, and her affect was constricted and blunted. Progress group notes indicate the patient was respectful and compliant with group interventions but was overall quiet. A shift log indicated the patient was in a positive mood. She was somewhat disappointed over not (being able to do meals and attend a movie. Her school report card indicated a 95% in biology, 88% in physical education and a 95% in math.  Further, the submitted records do not indicate that the patient was under regular treatment by a child and adolescent psychiatrist while at the residential treatment center. The American Academy of Child and Adolescent Psychiatrists (AACAP) has indicated that residential treatment should: Include a child and adolescent psychiatrist or in the case of an adolescent program, an adult psychiatrist with training in treating that age group. The psychiatrist should also meet with the patient once a week or more as clinically indicated, (Houston, et al). The services provided do not appear to meet those criteria, as there is no evidence of weekly psychiatric visits with a psychiatrist.  While the patient required treatment to further improve social functioning, mood, interpersonal relationships, as well as family relationships, the patient did not require the restrictiveness of a residential psychiatric treatment facility in order to receive care during the period at issue. Residential services are not evidenced based for long-term type treatment. Outpatient treatment and least restrictive options are considered first lines of care as referenced by AACAP, which recommends that children and adolescents be treated in the least restrictive setting possible and to maintain and foster natural supports. All told, the patient was no longer experiencing symptomatology that required the intensity of residential treatment level of care. Although the patient required continued treatment, step-down to a less intensive level of care would have medically appropriate. Therefore, residential treatment center services  were not medically necessary. 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