Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement for residential acute behavioral health level of care.  The submitted records support the services at issue in this clinical setting. The patient was noted to have continued depressive symptoms, and the progress notes indicated she had extremely limited insight into her need for treatment. She appeared minimally cooperative in treatment. She also had issues with aggression and behavior problems at home, and her parents were concerned regarding the safety of her siblings. The patient also had a history of suicidal ideation.An evidence-based instrument such as the American Academy of Child and Adolescent Psychiatry and American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) is indispensable in determining necessary level of care for children.  In terms of risk of harm, the records support a score of 3 due to her repetitive suicidal ideation. With regards to functional status, the records support a score of 4 due to numerous disruptions in treatment. In terms of comorbidity, the records support a score of 2. The patient did not have significant medical or substance use issues. With regards to level of stress of the recovery environment, the records support a score of 4. The progress notes indicate that the patients home life was stressful due to the strained relationship with her parents. In terms of level of support for the recovery environment, the records support a score of 4. The patients primary caretakers are reported to have difficulty with emotional support in an appropriate manner. With regards to resiliency and treatment history, the records support a score of 5 due to minimal positive treatment response in the past as well as current difficulties with treatment response. In terms of acceptance and engagement of the patient, the records support a score of 4. The patient had minimal insight into her treatment needs, and appeared to blame treatment staff for her lack of success in treatment. With regards to acceptance and engagement of the parents, the records support a score of 2. The parents appear to work with clinicians but had some difficulty creating a definition of the problem. Thus, the patient has a composite score of 28. This score correlated with residential treatment level of care. The medical evidence supports the services at issue in this clinical setting. Therefore, residential acute behavioral health level of care was medically necessary for the 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 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.