Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The representative of an enrollee has requested reimbursement and prospective authorization and coverage for services provided 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. The patients risk of harm score is three (3), significant risk of harm. The patient does not have a history of suicide attempts. However, the patient has had five different episodes of suicidal ideation with a plan since 2005 with thoughts of overdosing or hanging himself. The patient has ongoing chronic suicidal ideation. The patients functional status score is three (3), moderate functional impairment. The patient has been depressed and had symptoms of amotivation, obsessive thoughts, hopelessness with chronic suicidal ideation. He would isolate and lament that he did not have any friends. Due to the nature of his autism spectrum disorder, the patient has very poor social skills. The patients co-morbidity score is three (3), significant co-morbidity. The patient has a co-morbidity of autism spectrum disorder, major depressive disorder, and ADHD. The patient does not have any medical problems which require 24 hour monitoring. The patients recovery environment stress score is two (2), mildly stressful environment. The patients parents are supportive of the patient. The patient will occasionally get into interpersonal conflicts with his mother. The patients environmental support score is two (2), supportive environment. The patients parents are supportive of the patient. The patients resiliency score is three (3), equivocal resiliency and response to treatment. The patient had prior treatment with the patients outpatient therapist and psychiatrist. The patient was recently started on Pristiq but this did not have time to take effect. The patients acceptance and engagement score is two (2), constructive. The patient appeared to want to engage in treatment. The patient was open and cooperated with clinicians. Based on these criteria, the patient has a composite score of 18 and met criteria for an IOP level of care. However, the patient reported that he felt that he had received enough benefit and did not wish to engage in further IOP treatment. On this date the patient also discussed his threat of self-harm . Howeever, given the patients behavioral health condition, it is not likely that he will have complete resolution of his self-harm ideation. Moreover, the patient made it clear that the patient wished to be treated in a less restrictive environment. Thus, the patient could have been treated in a less restrictive environment. Therefore, the a portion services offered  provided were  were medically necessary, however a portion of the  services provided from  forward were not medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that a portion of the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.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.