Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement and prospective authorization and coverage for residential treatment 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 two (2), some risk of harm. The patient does not have a history of any suicide attempts. The patients functional status score is three (3), moderate functional impairment. The patient has been failing school for the last six months and has not been engaged with studies. Previously, the patient was getting Bs in his schoolwork. The patient was suspended from school for bring razor blades to school. The patient reports that the patient gets along with peers and enjoys social activities. The patient has a conflicted relationship with parents due to running away, stealing money from his family, and wrecking cars after taking them without permission. Recent gains in stability have been achieved in structured and protective settings. The patients co-morbidity score is three (3), significant co-morbidity. The patient has a co-morbidity of ADHD, cannabis use disorder, and generalized anxiety disorder. The patients substance use is the primary problem for the patients admission to the RTC. The patient does not have any major medical problems. The patients recovery environmental stress score is three (3), moderately stressful environment. The patient has a significant stress in the family milieu due to conflicts over the patients cannabis use, stealing, failing grades, and other impulsive behavior. The patients environmental support score is three (3), limited support in environment. The patients resiliency score is three (3), equivocal response to treatment. Prior treatments have not been able to keep the patient sober from his cannabis use. The patient has an inconsistent capacity to deal with stressors and maintain a normal development. The patients acceptance and engagement score is three (3), obstructive. The patient is cooperative with staff, but the patient will minimize and rationalize problem behaviors and consequences. However, the patient does engage in therapy sessions. Based on these criteria, the patient has a composite score of 20 and meets criteria for a partial hospitalization program (PHP). The patient could have been treated in a less restrictive environment. Although the patient does struggle with impulsivity, anxiety, insomnia, and ADHD, the documentation presented states that the patients main problem is cannabis use disorder. The services at issue are not the standard of care for the treatment of cannabis use disorder. The patient could be treated in a PHP, attend 12-step programs, and engage in a sober living environment. This will allow the patient to utilize skills learning in treatment to cope with everyday stressors and challenges and continue to remain sober. 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 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.