Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement and prospective authorization and coverage for residential treatment for treatment of the enrollees behavioral health condition. 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 has a history of overdosing on Xanax and Klonopin. The patients functional status score is four (4), serious functional impairment. The patient was very impulsive and appeared to have little control over his substance use. Prior to admission, the patient was focused only on obtaining substances and getting high. The patient has been expelled from school for using substances at school, bringing in drug paraphernalia, and sending death threats against the principal. The patients co-morbidity score is three (3), significant co-morbidity. The patient has a co-morbidity of major depressive disorder, generalized anxiety disorder, cannabis use disorder, hypnotic and anxiolytic use disorder, and autism spectrum disorder. The patient does not have any major medical problems. The patients recovery environmental stress score is three (3), moderately stressful environment. The patient has difficulty with social situations due to his autism spectrum disorder. The patient has serious interpersonal difficulties with parents over the patients substance use. The patients environmental support score is three (3), limited support in environment. The patients resiliency score is three (3), equivocal resiliency and response to treatment. The patient has had a mixture of outpatient and residential treatment. The patient has been unable to stay sober after completion of these treatments. The patients acceptance and engagement score is four (4), adversarial. Prior to admission, the patient would not comply with treatment recommendations and had no desire to stay sober. Based on these criteria, the patient has a composite score of 23 and met criteria for RTC level of care. However, after 3 months, the patient had achieved significant improvement. The patient was participating in groups and engaging in treatment. The patient did not have any suicidal ideation at that time and the patient could have been treated in a less restrictive environment. 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.