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

Nature of Statutory Criteria/Case Summary: At issue in this case is whether the residential treatment center (RTC) services were and/or are medically necessary for treatment of the patients behavioral health issues. 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, treaters 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. Applying the CALOCUS to this patients case, the patient does not meet the criteria for RTC. The patient presents with some risk of harm (score 2), as she has not been actively suicidal and has not engaged in self-harm, but has a history of these issues. The patient has demonstrated some mild functional impairment (score 2) given her mental illness and anxiety, but has demonstrated appropriate daily functioning while in treatment as evidenced by intact activities of daily living and cooperation in treatment. The patient has no reported co-morbidities (score 1) with no history of medical issues or substance use. The patients recovery environment is mildly stressful (score 2) as she has a good relationship with her family, and her recovery environment is supportive (score 2), as the patients parents are involved in treatment. The patient has demonstrated some response to prior treatment (score 3) as she reported improved symptom presentation while she was at the RTC prior to the admission under review. She continued to exhibit symptoms of anxiety and depression. She was participating in therapy programming while on the unit and was not displaying any serious or disruptive symptoms. Overall, the patient has been constructive in treatment (score 2) and is reported to participate in all types of therapy on a regular basis. The patients parents have also been involved in treatment (score 2) as they have consistently worked with the patients providers. This gives the patients presentation a composite score of 16, which correlates with outpatient services. Thus, the RTC services were not and are not medically necessary for treatment of this patients behavioral health issues. Final Result: The reviewer determined that the requested services 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 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.