Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement for (1) all or any of the acute psychiatric inpatient treatment services rendered at Brynn Marr Hospital, and (2) all or any of the residential treatment center (RTC) services provided at New Hope Carolinas.At issue is whether all or any of the acute psychiatric inpatient treatment services rendered at Brynn Marr Hospital were medically necessary for the treatment of this patient. The Child and Adolescent Level of Care Utilization System (CALOCUS) provides a framework for determining the clinically appropriate level of care for a child or adolescent in mental health treatment. With regard to risk of harm, the records support a score of 3. The patient had a significant risk of harm, due to recent verbal threats of property destruction and physical aggression. In terms of functional status, the records support a score of 3. The documentation noted the patient appeared to be able to function fairly, holding a job and doing well in school until recently, despite significant family conflict and a diagnosis of bipolar disorder. With regard to comorbidity, the records support a score of 3. The patient had significant comorbidity due to a diagnosis of bipolar disorder. In terms of level of stress of the recovery environment, the records support a score of 4. The patient had a very stressful environment due to severe conflicts with his adoptive mother. With regard to level of support of the recovery environment, the records support a score of 2 due to a conflictual relationship with his parents.In terms of resiliency and treatment history, the records support a score of 3. The patient had moderate or equivocal resiliency and/or response to treatment due to his ability to hold a job and do well in school until recently. He functioned fairly while hospitalized, participating in group sessions and being cooperative with staff.With regard to treatment acceptance and engagement, the records support a score of 4 due to his parents appearing non-collaborative and refusing to take the patient home. Thus, the patient has a total score of 22. In this case, the recommended level of care is medically monitored community-based services. Therefore, all of the acute psychiatric inpatient treatment services rendered at Brynn Marr Hospital were not medically necessary for the treatment of this patient. At issue is whether and all or any of the RTC services at New Hope Carolinas were medically necessary for the treatment of this patient.The Child and Adolescent Level of Care Utilization System (CALOCUS) provides a framework for determining the clinically appropriate level of care for a child or adolescent in mental health treatment. With regard to risk of harm, the records support a score of 2. The patient had some risk of harm, due to a history of verbal threats of property destruction and physical aggression. The records did not note suicidal ideation.In terms of functional status, the records support a score of 3. The documentation noted that the patient appeared to be able to function fairly, holding a job and doing well in school until recently, despite significant family conflict and a diagnosis of bipolar disorder.  He functioned fairly while hospitalized, participating in group sessions and being cooperative with staff.With regard to comorbidity, the records support a score of 3. The patient had significant comorbidity due to a diagnosis of bipolar disorder. In terms of level of stress of the recovery environment, the records support a score of 4. The patient had a very stressful environment due to severe conflicts with his adoptive mother. With regard to level of support of the recovery environment, the records support a score of 2 due to a conflictual relationship with his parents.In terms of resiliency and treatment history, the records support a score of 3. The patient had moderate or equivocal resiliency and/or response to treatment due to his ability to hold a job and do well in school until recently. He functioned fairly while hospitalized, participating in group sessions and being cooperative with staff, but had a history of noncompliance with treatment, verbal and physical aggression.With regard to treatment acceptance and engagement, the records support a score of 4 due to the parents appearing noncollaborative and requesting that the patient not be returned home. Thus, the patient has a total score of 21. In this case, the recommended level of care is medically monitored community-based services.  Given that community-based services were not readily available due to the COVID-19 pandemic, medically monitored residence-based services were medically indicated. Therefore, RTC services provided at New Hope Carolinas were medically necessary for the treatment of this patient.   Final Result: The reviewer determined that the services at issue were partially 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 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.