Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of a 17-year-old male enrollee has requested reimbursement for the residential treatment services. The records provided for review do not support the medical necessity of the residential treatment services for treatment of this patients behavioral health issues. During his stay, the patient was noted to be cooperative in treatment. He was noted to have some anxiety and shyness, and his mood was noted to be euthymic. He was free from psychosis and his thoughts were clear and logical. He did not engage in any type of self-harm behavior or aggression toward his peers. He did not express any suicidal or homicidal ideation during his stay. The patient was not noted to struggle with substance use cravings during his stay. He was open in regards to his cravings and past use. He did not report any severe psychiatric symptoms. The progress notes indicate the patient had been treated with outpatient therapy prior to the residential treatment center admission. There was no indication of intensive outpatient treatment for his substance use or behavioral issues or mood or anxiety symptoms. According to the American Academy of Child and Adolescent Psychiatry (AACAP) practice parameters for treatment of oppositional defiant disorder, intensive in-home therapies such as multisystemic therapy, wraparound services, and family preservation models such as Homebuilders, which are often sponsored by child welfare agencies, are preferable alternatives to residential placement. Applying the Child and Adolescent Level of Care Utilization System (CALOCUS), the patient was a candidate for treatment at a lower level of care. The patient was at some risk of harm (score 2) due to his history of impulsive actions and substance use. However, the medical records indicate that the patient was not actively suicidal. The patient demonstrated moderate functional challenges (score 3) with reported school disruption due to substance use. The patient presented with no active serious medical problems, but a history of substance use (score 2). The patients recovery environment was mildly stressful (score 2) with a positive recovery environment and a stable housing situation. Moreover, the patients recovery environment was supportive (score 2) as his family was actively is involved in treatment. The patient showed limited response to previous treatment (score 3), but was noted to have a minimal history of outpatient treatment consisting of four months of treatment. Overall, the patient was constructive in treatment (score 2) as he was noted to participate in therapy and used coping skills learned in therapy. In addition, the patients parents were reported to work actively with the patients providers (score 2). This gives the patients presentation a composite score of 18 which correlates with intensive outpatient services. According to the CALOCUS the patient would need to have a score of 23-28 in order to require treatment in an RTC. As the patient could have been safely and effectively treated in a less restrictive setting, the residential treatment 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 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.