Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement for residential treatment center (RTC) services. Findings:  The physician reviewer found that For dimension 1, the patient was at serious risk of harm (score 4) due to recent aggression toward family members at home including threatening with a knife. This was followed by homicidal threats and urges while at the RTC. The patients grandparents decided not to allow her to return home after discharge from RTC due to concerns about these behaviors and threats. Prior to her admission, the patient also engaged in risky behaviors and substance use. The RTC staff were concerned about a recurrence of these behaviors upon her discharge. The records support indication or report of significant impulsivity and physical aggression with poor judgment and insight and is significantly endangering to self or others. For dimension 2, the patient has demonstrated serious functional impairment (score 4) given serious deterioration of interpersonal interactions, as demonstrated by threats toward her family members and homicidal thoughts expressed at the RTC. Also, the patient stopped all academic work and was at risk of not graduating. There is documentation of serious deterioration of interpersonal interactions with consistent or otherwise disrupted interactions with others, which may include impulsive or abusive behaviors. For dimension 3, the patient has significant co-occurrences (score 3) due to frequent use of cannabis edibles, which stopped in the protected setting of the RTC. The RTC discharge summary indicated that the patient was at risk of relapse upon discharge. Substance abuse was present, with significant adverse effect on the functioning and the presenting condition. For dimension 4, the patients recovery environment was highly stressful (score 4) due to the passing of her mother from cancer, violence in her neighborhood, lack of regular contact with her father, and plan for the patient to move to another state upon discharge rather than return home. There is documentation of serious disruption of family and social milieu due to death and separation of parent and adolescent. For dimension 4B, the patients recovery environment provided limited support (score 3) due to her grandfathers refusal to participate actively in treatment. The patients grandmother tried to care for the patient prior to her admission to the RTC, and continued to participate in treatment, but she ultimately felt that the patient needed to live elsewhere upon discharge. The patients family had limited ability to respond appropriately to the patients developmental needs and problems and was ambivalent toward meeting those needs and addressing those problems. For dimension 5, the patient exhibited poor resiliency and response to treatment (score 4) since she continued to struggle after years of outpatient treatment, an inpatient hospitalization, and weeks of treatment at the residential level. Previous treatment did not achieve complete remission of symptoms or optimal control of symptoms even with intensive and repeated exposure to interventions. For dimension 6, the patient showed limited engaged in treatment (score 3). The records document that the patient participated in sessions, but at times glorified her substance use and expressed defiance toward her grandparents. The records support ambivalent, avoidant, or distrustful relationship with clinicians and other care providers. These findings give the patient a composite score of 25, which is consistent with medically monitored intensive integrated services. Moreover, the RTC services provided were in accordance with the generally accepted standards of mental health and substance use disorder care, clinically appropriate in terms of type, frequency, extent, site, and duration, and not primarily for the convenience of the patient or provider. Given these findings, the RTC services were medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in psychiatry with subspecialty 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.