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

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement for residential treatment center (RTC) services. The American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) provides a reliable framework for determining the appropriate level of care for adolescents needing mental health treatment. Using CALOCUS, providers score patients on a scale of 1-5 using a six-pronged Dimensional Rating System. The six dimensions include: (1) risk of harm; (2) functional status; (3) medical, addictive and psychiatric comorbidity; (4) recovery environment (a. stressors and b. supports); (5) treatment and recovery history; and (6) engagement. The composite score is then used to determine the level of care needed. Applying the CALOCUS criteria, the patient had some risk of harm (score 2) as the medical records indicate that the patient was passively suicidal without plans to harm herself. The patient was initially admitted to the RTC due to depression and anxiety with suicidal ideation. However, the patient did not have active suicidal or homicidal ideation or psychosis, and did not display aggression towards peers or staff during disputed time frame. The patient showed mild functional impairment (score 2) but the progress notes indicate significant improvement after a period of deterioration, with appropriate performance of activities of daily living. The patient did not have any medical problems (score 2) and the records suggest the patients substance use was in remission and not affecting her psychiatric issues. The progress notes did not describe any significant unresolved mood or anxiety symptoms. The progress notes indicate the patients mood and anxiety significantly improved. The patients recovery environment was mildly stressful (score 2) and the patients parents were supportive (score 2) as they were actively involved in regular treatment activities. The patient demonstrated positive response to treatment (score 2) with improvement in therapy. The records document the patient showed cooperative behaviors and insight into her need for continued treatment. Overall, the patient was constructive in treatment (score 2) as she actively participated in therapy and her insight and judgment were noted to be fair throughout treatment. The patient was cooperative with staff and peers well as with activities in therapy. The patients parents were also constructive (score 2) as they worked actively with the patients providers. This gives the patients presentation a composite score of 16, which correlates with a treatment intensity level of two which correlates with outpatient services. Given these findings, the patient was a candidate for treatment in a less restrictive treatment setting than RTC during the period under review. Accordingly, the RTC services were not medically necessary for treatment of this patient.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 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.