Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement for residential treatment center (RTC) services.  For dimension 1, the patient was at serious risk of harm (score 4) due to suicide attempts by overdose on two occasions and self-harm behaviors in the form of cutting. On admission, the patient endorsed continued suicidal ideation. In addition, the patient has a history of significant substance use with only recent attempt to remain abstinent. The records indicated that the patient no longer reported suicidal ideation, but it was noted that patient could be manipulative with his providers. The provider noted that the patient continued to be highly impulsive and struggle with emotional regulation when distressed. Current suicidal ideation with either clear, expressed intentions and/or past history of carrying out such behavior. The patient expressed ambivalence about carryout out the safety plan. For dimension 2, the patient demonstrated serious functional impairment (score 4) given his poor academic performance with poor grades. The patient exhibited difficulty managing his anger, threatened people, and become verbally aggressive. The patient was also engaging in sexually aggressive behaviors that had the potential to harm others. The provider noted that the patient had difficulty maintaining appropriate hygiene even while in treatment and receiving multiple reminders and support. Serious deterioration of interpersonal interactions with consistent conflict or otherwise disrupted interactions with others, which may include impulsive or abusive behaviors. For dimension 3, the patient had major comorbidities (score 4) considering his history of significant substance use with use of opiates, benzodiazepines, and cannabis on a regular basis. The patient also has cerebral palsy and an enlarged liver. Medical conditions are present that will adversely affect, or be adversely affected by, the presenting condition. For dimension 4A, the patients recovery environment was moderately stressful (score 3). The records document that the patient was frequently in conflict with his parents, and he experienced difficulty accepting the limits and boundaries set by his parents. He was frequently in trouble at school for his substance use. The patients mother struggles with anxiety and has difficulty managing her anxiety. The patients parents were not aligned in their parenting. Disruption of family milieu. For dimension 4B, the patients recovery environment provided limited support (score 3) since his parents appeared to be engaged in the patients treatment, but they struggled to respond appropriately to the patients needs. His parents continued to struggle with setting clear and consistent limits with the patient. Family had limited ability to respond appropriately to the patients developmental needs and problems or was ambivalent toward meeting these needs or addressing these problems. For dimension 5, the patient exhibited poor resiliency and response to treatment (score 4). The patient was previously in an intensive outpatient program and was unable to achieve complete remission of his symptoms as he continued to engage in substance use while participating in the program. The provider noted that the patients ability to meet expectations in RTC were inconsistent and mood dependent. He was also noted to have increased conflict and resistance to meeting expectations as developmental pressures and life changes have become greater. Previous treatment has not achieved complete remission of symptoms or optimal control of symptoms even with intensive and repeated exposure to treatment. For dimension 6, the patient was non-collaborative in treatment (score 4) given his ambivalent, avoidant, and at times distrustful behaviors toward clinicians and other care providers. The provider noted that the patient looked for ways around meeting expectations or giving up on expectations rather than trying to solve or change his behaviors. The patient also used excuses for his lack of engagement in the treatment program. Accepted no age-appropriate responsibility with clinicians and other care providers despite competent efforts to engage with the patient. These findings give the patient a composite score of 26, which is consistent with medically monitored residence-based services. Per CALOCUS, the patients scores on risk of harm and comorbidities also supports treatment at Level 5 medically monitored residence-based services. Furthermore, 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 were not primarily for the convenience of the patient or provider. All told, 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.