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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for (1) residential treatment center (RTC) services, (2) a 90-day RTC program, (3) a 60-day RTC program, or (4) a 30-day RTC program. 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.  Although the patient is age 18, the CALOCUS criteria will be used instead of the adult criteria, due to her developmental status as she is under the care of and living with her parents and attending high school.With regard to risk of harm, the records support a score of 3. The patient has a significant risk of harm, due to a history of hospitalization for suicidal ideation. In terms of functional status, the records support a score of 4. The documentation noted serious functional impairment due to significant withdrawal and avoidance of almost all social interaction. The patient was refusing to leave the home, not getting out of bed, and not participating in online school. With regard to comorbidity, the records support a score of 1. The patient does not have comorbidities. In terms of level of stress of the recovery environment, the records support a score of 2. The patient has a mildly stressful environment due to academic pressures and disruptions caused by the pandemic. With regard to level of support of the recovery environment, the records support a score of 2 due to her mothers participation in treatment and treatment planning. In terms of resiliency and treatment history, the records support a score of 4. The patient has poor resiliency and/or response to treatment due to persistent mood and anxiety symptoms despite multiple medication trials, outpatient therapy, a psychiatric hospitalization, four attempts at partial hospitalization program (PHP), and participation in an intensive outpatient program (IOP). The patient struggled to participate in a recent short-term residential stay. With regard to treatment acceptance and engagement, the records support a score of 3. The patient demonstrated incomplete engagement, due to her difficulty in participating in treatment. Thus, the patient has a total score of 19. The records support a 4 in terms of functional status. In this case, the recommended level of care is medically monitored residence-based services. With the functional impairment noted, the patient meets CALOCUS 5b extended stay criteria. This is consisted with the RTC level of care being requested. In this patients case, RTC level of care is in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the requested services are clinically appropriate in terms of type, frequency, extent, site, and duration. The requested services are not primarily for the economic benefit of the health care service plan and subscribers or for the convenience of the patient, treating physician, or other health care provider. Therefore, a 60-day RTC program is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested services 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 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.