Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement of all or any of the residential treatment center (RTC) services provided from 6/1/17 through 8/30/17. The Health Plan has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees bipolar disorder, and attention deficit hyperactivity disorder (ADHD). At issue in this case is whether the requested residential treatment center services provided from 6/1/17 through 8/30/17 were medically necessary for treatment of the enrollees behavioral health condition.During the disputed timeframe, the patient showed cooperative behavior and treatment progress. She was admitted due to apparent behaviors of lying and running away from home as well as some cannabis use. Admission evaluation indicates that she had not been in behavioral health services prior to her admission. At times during treatment, she expressed some lack of motivation for treatment but was cooperative in the process at the treatment center.She followed all treatment programming as she was instructed. The progress notes indicate that she was open and honest in regards to her feelings about her mood, conflicts with peers and other problematic issues. She did not have active suicidal or homicidal ideation and did not engage in self-harm. She was eating and sleeping well.The patient did not display aggression towards peers or staff during the disputed period. Her family was involved with treatment. The patient did not express any symptoms of psychosis. The records do not document any severe mood or anxiety symptoms or any serious behavioral issues.  The CALOCUS score is noted below is for the disputed period as assessed by the patients symptoms:1)   Risk of harm--- some (2), the medical records indicate that the patient was not actively suicidal at any time but had a history of suicidal ideation recently.2)  Functional status--- mild (2), the patient has had some issues with level of function due to mental illness and relational issues but overall showed appropriate daily functioning.3) Co-Morbidity---minor (2), the patient does not have active medical problems. She has a history of cannabis use without any signs or symptoms of substance withdrawal. 4A) Recovery environment, level of stress---mild (2), the patient was noted to have mild interpersonal conflict with the family members due to her behaviors of running from home. However, the progress notes document that her relationship and family sessions were productive and were not adversarial. 4B) Recovery environment, level of supportsupportive (2), the patients parents are involved in treatment on a regular basis and appear to understand the patients needs.5) Resiliency and Treatment history moderate/equivocal (3), it appears that the patient has had response to a short period in the RTC. She was participating in therapy programming and was not displaying any serious or disruptive symptoms.6A) Acceptance and engagement, child/adolescent---constructive (2), the patient participates in therapy actively and was cooperative with consistent engagement and no apparent disruptive behavioral issues while in treatment.6B) Acceptance and Engagement, Parent---constructive (2), the parents work actively and constructively with clinicians on a regular basis. This gives the patients CALOCUS presentation a composite score of 17. This score correlates with a treatment intensity level of three which correlates with Intensive Outpatient Services`. Therefore, the residential treatment center services were not medically necessary.Final Result: The reviewer determined that the services at issue were 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 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.