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

Nature of Statutory Criteria/Case Summary:  The parent of an enrollee has requested reimbursement for residential treatment center (RTC) services provided by the Center for Change from 12/14/20 through 12/16/20.At issue in this case is whether RTC services provided by the Center for Change from 12/14/20 through 12/16/20 were medically necessary to treat the patients medical condition. 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 4. The patient had suicidal ideation during her stay at the RTC, and also struggled to consume enough food to establish and maintain a healthy weight. Prior to her admission to the RTC, she had been hospitalized and had required a nasogastric tube for feeding. In terms of functional status, the records support a score of 3. The documentation noted moderate functional impairment, due to difficulty engaging in family therapy and communicating with staff at the RTC.With regard to comorbidity, the records support a score of 3. The patient had significant comorbidity due to gastroparesis, nausea, constipation, and gastroesophageal reflux disease (GERD), which may have been related to her disordered eating.In terms of level of stress of the recovery environment, the records support a score of 2. The patient had a mildly stressful environment, due to disruptions caused by the COVID-19 pandemic.With regard to level of support of the recovery environment, the records support a score of 2 due to her parents' involvement in treatment.In terms of resiliency and treatment history, the records support a score of 4. The records document poor resiliency and/or response to treatment due to the patients struggle with suicidality, depressed mood, anxiety, and disordered eating after extended time in outpatient therapy, a psychiatric hospitalization, and residential treatment. With regard to treatment acceptance and engagement, the records support a score of 3. Although the patient participated in therapy, she resisted eating her prescribed meals and was hiding food in her room.Thus, the patient has a total score of 21. Due to the  score of 4 in terms of the patients risk of harm, medically monitored residence based services were indicated.  Furthermore, the patient qualified for Level 5B: Intermediate Stay Medically Monitored Residential programs, due to her ambivalence about treatment, difficulty in fully engaging in the diet plan for her disordered eating, and lack of response to previous care. Per CALOCUS, the recommended length of stay at Level 5B is up to 60 days. The patient participated in residential treatment for about six weeks, which was well within the recommended guidelines. Also, the patients symptoms and behavior during residential treatment continued to demonstrate the need for this level of care. Thus, the RTC services provided by the Center for Change from 12/14/20 through 12/16/20 were medically necessary for the treatment of the patients medical condition. Final Result: The reviewer determined that the services at issue were 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 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.