Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement for residential treatment center services provided from 6/28/18 going forward. The Health Plan has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees depression, anxiety, and substance abuse. A review of the record indicates that the enrollee has been diagnosed with depression, anxiety, and substance abuse. In a report dated 6/29/18, the enrollees provider noted that the enrollee presented with a very low risk of suicide and that the enrollee was pleasant and cooperative. The enrollee stated that she had never had suicidal thoughts. The enrollee was alert and oriented with no evidence of disordered thinking. The enrollees provider recommended residential treatment center services from 6/28/18 going forward for the enrollee.At issue in this case is whether the requested residential treatment center services from 6/28/18 going forward were medically necessary for treatment of the patients medical condition. During the disputed timeframe, the patient showed cooperative behavior and treatment progress. She was not noted to have any difficulties with staff or peers and 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 past substance use, her mood and her relationship with her family. The patient was noted to have learned coping skills while in the wilderness treatment program directly prior to her residential treatment center admission. The patient did not display aggression towards peers or staff. The patient did not express any significant mood or anxiety symptoms. The patient did not express any symptoms of psychosis. The CALOCUS scoring is noted below for the disputed period as assessed by the patients symptoms:1)  Risk of harm--- low (1), the medical records indicate that the patient was not actively suicidal at any time and had no history of suicidal ideation. 2)  Functional status--- mild (2), the patient has had some issues with level of function due to her substance use but the progress notes indicate significant improvement after a period of deterioration as evidenced by her active participation in her wilderness program directly prior to her residential treatment center admission.3) Co-Morbidity---minor (2), the patient does not have active medical problems and has a history of cannabis use issues and mental health symptoms. She described only mild mood symptoms on admission. There was no documentation of any withdrawal symptoms from any substances.4A) Recovery environment, level of stress---moderate (3), the patient was noted to have interpersonal conflict with the family members due to her substance use. However, the progress notes document that her relationship and phone calls with family were productive and amicable. There was noted substance use in her family.4B) Recovery environment, level of supportsupportive (2), the patients parents are involved in treatment on a regular basis.5) Resiliency and Treatment historymoderate/equivocal (3), it appears that the patient has had good response to a short period in the wilderness program. She described learning coping skills while there.6A) Acceptance and engagement, child/adolescent---constructive (2), the patient participates in therapy actively and she was cooperative with consistent engagement and no apparent 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 presentation a composite score of 17. This score correlates with a treatment intensity level of three which correlates with `Intensive Outpatient Services.` This score is judged by the acuity of the patients symptoms and environment during the period under dispute at the residential treatment center, as of the date of denied health plan authorization. According to the CALOCUS, the patient would need to have a score of 23-28 in order to require treatment in a residential treatment center. Therefore, the residential treatment center services were not medically necessary.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 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.