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

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) and partial hospitalization program (PHP) 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 CALOCUS, this patient meets the criteria for RTC services and PHP services. The patient has been at significant risk of harm (score 3) due to recent suicidal ideation with specific plans. The patient posted on social media regarding his suicidal intent. The records document that the patient has demonstrated moderate functional impairment (score 3) and has been refusing to attend school. The patient experienced significant weight loss of 20 pounds in three months followed by recent gains in highly structured settings. The records document significant comorbidity given the patients recent 20-pound weight loss (score 3). The patients recovery environment has been mildly stressful (score 2) due to some conflict with his parents. The patients parents have been highly supportive (score 1). The patient has shown moderate response to treatment (score 3) due to recent recovery in a highly structured setting, after several weeks of inpatient and RTC levels of care. The patient has been constructive in treatment (score 2) as the provider noted that the patient has expressed his feelings about being forced into recovery. This gives the patient a composite score of 17, which is consistent with IOP services. However, the patient only achieved this level of functioning recently, in a highly structured setting. Consistent with the patients current treatment plan, the patient was stepped down from RTC to PHP based on this progress. The additional days at the RTC and PHP levels of care will help the patient solidify his recent treatment gains before transitioning to an IOP. This gradual approach will allow the patient and his family to readjust to being at home, with gradually decreasing structure and support. There is significant risk that after almost two months in inpatient and RTC treatment, a rapid discharge to an IOP program could result in a recurrence of depression, anxiety, and suicidal ideation for the patient. Given these findings, the RTC level of care services, and PHP level of care services, were and are medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were and are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. 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.