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) 60 days of residential treatment center (RTC) services, (2) 45 days of RTC services, or (3) 30 days of RTC services. 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 potential cardiac sequelae from dietary restriction and overexercise.In terms of functional status, the records support a score of 4. The documentation noted serious functional impairment due to overexercise and dietary restrictions. The records note two hospitalizations this year for her eating disorder which would have disrupted her school and social activities. With regard to comorbidity, the records support a score of 4. The patient had major comorbidity, due to the patients low weight and eating disorder most resembling anorexia nervosa, a serious medical illness with the highest mortality rate of any psychiatric illness that compromises cardiac functioning and may lead to sudden cardiac death. The patient was noted to have bradycardia and amenorrhea and to be at risk for refeeding syndrome.In terms of level of stress of the recovery environment, the records support a score of 3. The patient had a moderately stressful environment due to two hospitalizations this year for medical complications resulting from her eating disorder. With regard to level of support of the recovery environment, the records support a score of 3 due to her parents seeking treatment. 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 two hospitalizations this year for medical complications resulting from her eating disorder. With regard to treatment acceptance and engagement, the records support a score of 3. The patient had reasonable insight into her eating disorder. Thus, the patient has a total score of 25. The records support a 4 in terms of risk of harm, functional status, and comorbidity. In this case, the recommended level of care is medically monitored residence-based services. With the elevated risk of harm, functional status, and comorbidity noted, the patient meets CALOCUS 5b extended stay criteria. This is consistent with the level of care that the patient is requesting at the RTC. 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, 60 days of RTC services are 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.