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 (RTC) services. The Health Plan has denied this request indicating that the services at issue were not and are not medically necessary for treatment of the enrollees behavioral health condition.Based on the documentation submitted for review, the RTC services provided were not and are not medically necessary for treatment of the patients medical condition. The progress notes submitted for review indicate that the patient reported symptoms of anxiety that were in the mild category. During the patients stay the patient was noted to be cooperative and was benefiting from therapies. The patient was noted to be receptive to peer and therapist feedback. The patient had offsite passes with parents without any significant behavioral problems or severe psychiatric symptoms other than logging on to social media accounts without permission. The progress notes did not indicate the patient was aggressive with peers or staff.  The progress notes did not indicate the patient had any active suicidal ideation. In addition, based on the Child and Adolescent Level of Care Utilization System (CALOCUS), the patient scored a composite score of 18, which correlates with a lower level of care. This score is judged by the acuity of the patients symptoms and environment during the period under dispute. In this case, the patients risk of harm was two (2), some risk of harm. The patient has a history of depression and anxiety. However, the medical records indicate that the patient was not actively suicidal during the residential treatment center stay. The patients functional status was three (3), moderate. The patient has had some issues with inappropriate relationships with peers and lack of school attendance. The patients co-morbidity was two (2), mild. The patient did not have active serious medical problems or any significant substance use issues other than some minimal substance experimentation. The patients recovery environmental level of stress was two (2), mild. The patient has a positive recovery environment and a stable housing situation. The patients recovery environment level of support was two (2), supportive. The patients parents were continually involved in treatment as evidenced by their participation in frequent family therapy sessions. The patients resiliency and treatment history was three (3), moderate. The patient had no significant treatment successes. The patients acceptance and engagement, child/adolescent was two (2), constructive. The patient participates in therapy and has used coping skills learned in therapy per the records. The patients acceptance and engagement, parent was two (2), constructive. The parents worked actively and constructively with the providers. The patient scored a composite score of 18, which correlates with a lower level of care. For the reasons provided, the services at issue were not and are not medically necessary for treatment of the patients behavioral health 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 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.