Appeal type: Medical Necessity
Decision: Upheld 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) 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. Based on the available documentation, the patient presents with some risk of harm (score 2) as the medical records indicate that the patient was not actively suicidal at any time, although he had recent passive suicidal ideation without intent to harm himself. The patients functional status is mildly impaired (score 2) due to difficulties with mental illness and substance use. The records indicate the patient has demonstrated appropriate daily functioning while in treatment including intact activities of daily living. The patient presents with significant comorbidity (score 3) as he does not have active medical problems, but his substance use has impacted his mood and anxiety. The records note that he was not experiencing any withdrawal symptoms. The patients recovery environment is mildly stressful (score 2) and the patients discharge plan was to return to home. The patients recovery environment is supportive (score 2) as his parents are involved in treatment on a regular basis. The patient has participated in minimal prior treatment (score 3) with one month of outpatient services. The patient has become constructive with treatment (score 2). The records document the patient did not initially participate in therapy, but has been described as cooperative without any oppositional behaviors. Moreover, the patient has been open to discuss his difficulties and appears to understand the risk factors of his substance use. The patients parents have been constructive (score 2), as they have worked actively with the patients providers on a regular basis. This gives the patients presentation a composite score of 18, which correlates with intensive outpatient services. Thus, the RTC services provided were not and are not medically necessary for treatment of this patients behavioral health issues. Final Result: The reviewer determined that the services at issue were not and are 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.