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

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for (1) admission to a 45-day dual diagnosis RTC program or (2) admission to a 30-day dual diagnosis 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.With regard to risk of harm, the records support a score of 4. The patient had a serious risk of harm, due to being hospitalized three times within the last nine months for suicide attempts and suicidal ideation, and a history of substance abuse and difficulty with sobriety. The patient reported suicidal ideation two to three times weekly, starting in 7th grade, most recently with thoughts to jump out of the car on day of she was admitted to the RTC. The patient also reported a history of suicide attempts beginning in 8th grade, totaling 16 attempts, with the most recent plan being two weeks prior to admission to the RTC. The patient reported a history of self-harm starting in the 8th grade, using scissors to cut herself on her hip most recently two weeks prior. In terms of functional status, the records support a score of 3. The documentation noted moderate functional impairment due to the patients reports of stealing, compulsive and risky behavior, poor hygiene, and alcohol and substance use. With regard to comorbidity, the records support a score of 3. The patient had significant comorbidity, due to the presence of bladder problems, significant anxiety, impulsivity, and substance use. In terms of level of stress of the recovery environment, the records support a score of 4. The patient had a highly stressful environment due to disruption of family/social milieu as her parents were divorced and her father had a history of bipolar disorder and aggression. The patient lived with her mother and reported difficulty avoiding substance use. With regard to level of support of the recovery environment, the records support a score of 4 due to severe conflicts with her parents. In terms of resiliency and treatment history, the records support a score of 4. The patient had poor response to treatment and recovery management due to limited response to outpatient treatment and an inability to maintain sobriety or manage moods and suicidality. With regard to treatment acceptance and engagement, the records support a score of 2. The patient appeared cooperative and engaged in treatment. Thus, the patient has a total score of 24. The records support a 4 in terms of risk of harm. In this case, the recommended level of care is medically monitored residence-based services. With the elevated risk of harm noted, the patient meets CALOCUS 5b extended stay criteria. This is consistent with the level of care that the patients parent is requesting. 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, admission to a 45-day dual diagnosis 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.