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 center services and forward. 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. As of the date of service in question, the patients risk of harm score is three (3), serious risk of harm. The patient has a history of cutting. The patient does not have a history of suicide attempts. The patient threatened to burn her school down which could have seriously injured others. The patients functional status score is three (3), moderate functional impairment. The patient is intelligent, but lacks motivation to do well in school. She has conflicted relationships with her peers and her parents. She has very few friends. She was suspended due to threatening to burn down her school. The patients co-morbidity score is three (3), significant co-morbidity. The patient has a co-morbidity of disrupted mood dysregulation disorder, generalized anxiety disorder, and oppositional defiant disorder. The patient did not have any medical problems which required 24-hour monitoring. The patients recovery environmental stress score is two (2), mildly stressful environment. The patient has a supportive family. Expectations for performance at home and at school create discomfort. The patients environmental support score is two (2), supportive environment. The patient has supportive parents who are willing to participate in treatment.  The patients resiliency score is four (4), given her poor response to treatment. Prior outpatient and IOP services were ineffective. The patient was guarded, refused medications, and would not participate in treatment. The patients acceptance and engagement score is three (3), obstructive. The patient is guarded, avoidant, and distrustful of providers. She minimizes her problems and behaviors. Based on these criteria, the patient has a composite score of 20 and meets the criteria for a partial hospitalization program (PHP). Thus, as of the date of service in question, the patient could have been treated in a less restrictive environment. Therefore, RTC services provided from the date of service in question, forward, 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 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.