Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for residential treatment services for three months. The submitted documentation fails to demonstrate the medical necessity of the requested services. The records documented social skills issues and mild family issues along with oppositional behaviors. The patient was noted to exhibit some oppositional behaviors in school and with some of her treatment programming. The progress notes do not describe the rationale for the admission to the disputed residential treatment program after her discharge from the initial residential treatment programs stay of approximately two months. She was not expressing active suicidal ideation or homicidal ideation during the disputed timeframe at the residential treatment center. The treatment progress notes did not indicate severe behavioral issues or violent outbursts. She did not display aggression towards peers or staff during the disputed timeframe. Her family was involved with treatment, and her family visits were described as successful. The patient did not have active substance use for several months prior to her admission due to being in a previous residential program where she was sober.  In cases such as this, an evidence-based instrument such as American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) assists in determining the necessary level of care for children. With regards to risk of harm, the records support a score of 1. The patient was not actively suicidal or aggressive. In terms of functional status, the records support a score of 2. The patient had some issues with level of function due to mental illness and oppositional behaviors, but overall showed appropriate daily functioning while in treatment as evidenced by intact activities of daily living. With regards to comorbidity, the records support a score of 2. The patient did not have a history of past medical issues. The records noted some past substance use issues which appeared to be in remission. In terms of level of stress of the recovery environment, the records support a score of 2. The patient was noted to have good relationship with family and denied current stress at home of a significant nature. Her family visits went well. With regards to level of support of the recovery environment, the records support a score of 2. The patients family was involved in treatment. In terms of resiliency and treatment history, the records support a score of 2. The patient reported improved symptom presentation while at the residential treatment center, and she was participating in therapy programming while on the unit. She was not displaying serious or disruptive symptoms. In terms of acceptance and engagement of the child, the records support a score of 2 to 3. The patient participated in therapy and indicated trust in her therapist. With regards to acceptance and engagement of the parent, the records support a score of 2. The patients parent worked actively and constructively with clinicians on a regular basis. Thus, the patient has a composite score of 15 to 16. This score correlates with outpatient services. Therefore, the requested residential treatment services for three months are not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested services 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.