Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement for residential treatment center (RTC) services. At issue is whether the RTC were medically necessary as defined in Health and Safety code section 1374(a)(3)(A) set forth below? Medically necessary treatment of a mental health or substance use disorder means a service or product addressing the specific needs of that patient, for the purpose of preventing, diagnosing, or treating an illness, injury, condition, or its symptoms, including minimizing the progression of that illness, injury, condition, or its symptoms, in a manner that is all of the following: (i) in accordance with the generally accepted standards of mental health and substance use disorder care; (ii) clinically appropriate in terms of type, frequency, extent, site, and duration; (iii) not primarily for the economic benefit of the health care service plan and subscribers or for the convenience of the patient, treating physician, or other health care provider.For dimension 1, the patient was at significant risk of harm (score 3) due to reports of varying degrees of suicidal ideation and self-harm urges. The provider noted that the patients suicidal ideation was reduced from prior periods. The patient has a history of one prior suicide attempt by overdose and a history of daily cutting prior to admission to RTC. No active suicidal ideation, but extreme distress and a history of suicidal behavior. For dimension 2, the patient demonstrated serious functional impairment (score 4) given her moderate ability to fulfill obligations while in RTC. The provider noted that the patient was inconsistent in completing assignments, struggled with self-motivation, and completed tasks only with prompting from staff. The records also indicate that the patients ability to fulfill obligations at home is low and that her inability to regulate her emotions negatively impacts her ability to meet daily expectations at home. Serious deterioration of interpersonal interactions with consistent conflict or otherwise disrupted interactions with others, which may include impulsive or abusive behaviors. For dimension 3, the patient has significant comorbidities (score 3) with insomnia, which can exacerbate depression. Conversely, depression can cause insomnia. The patient also struggled to maintain adequate nutrition, which can be due to depression but can also exacerbate it. Medical conditions are present that may adversely affect, or be adversely affected by, the presenting condition. For dimension 4A, the patients recovery environment was moderately stressful (score 3) considering the patients conflictual relationship with her parents. The patient indicated that she is highly resentful towards them. The patient has a learning disorder which causes additional school-related stress. Furthermore, prior to admission, patient was living in a group home due to the problems in her interpersonal relationships and social circumstances. This supports a disruption of family and social milieu. For dimension 4B, the patients recovery environment provided limited support (score 3). The provider noted that the patient lacks meaningful relationships with others, and she was reserved and guarded while at the RTC. Although her parents appear to be supportive, they demonstrate only partial ability to make necessary changes during treatment. The patient blames her parents for her difficulties. Family caretakers demonstrate only partial ability to make necessary changes during treatment. For dimension 5, the patient exhibited moderate or equivocal resiliency and response to treatment (score 3). The records document that the patients prior treatment history was limited due to non-compliance or non-attendance. The patient had one prior hospitalization and she was previously residing in a group home. She struggled to follow through with treatment recommendations while in RTC and prior treatment does not appear to have been successful in ameliorating symptoms or improve functioning. Previous experienced in treatment at low level of intensity was not successful in relief of symptoms or optimal control of symptoms. Has demonstrated limited ability to follow through with treatment recommendations. For dimension 6, the patient was non-collaborative in treatment (score 4) due to difficulty engaging in treatment. The provider noted that the patient was often defensive, hostile, withdrawn, and oppositional. The patient struggled with motivation and was unable or unwilling to take responsibility for her behaviors. The patient often blamed her parents for her depression. The records also describe using sarcasm, defensiveness, blaming, and passive and passive aggressive behaviors in family therapy sessions. Actively hostile relationship with clinicians and other care providers despite competent efforts to engage with the patient. Accepts no age-appropriate responsibility role in development, perpetuation, or consequences of the problem. These findings give the patient a composite score of 23, which is consistent with medically monitored residence-based services. Per CALOCUS, the patients score on level of function also supported Level 5 medically monitored residence-based services. Thus, the services at issue were in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the services at issue were clinically appropriate in terms of type, frequency, extent, site, and duration. The RTC services were not primarily for the economic benefit of the health care service plan and subscribers or for the convenience of the patient, treating physician, or other health care provider. Therefore, the RTC services were medically necessary as defined in Health and Safety code section 1374(a)(3)(A).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 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.