Appeal type: Medical Necessity
Decision: Overturned 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. Applying the CALOCUS framework, this patient meets the criteria for RTC services. The patient has been at significant risk of harm (score 3) due to her history of suicidality, self-harm, and excessive substance use. The patient has demonstrated serious functional impairment (score 4) given her conflict with her parents, failure to attend school, and restricting her dietary intake. The patient has been at significant comorbidity (score 3) considering her mental illness and substance abuse. The patient reports visual hallucinations and the provider described the patient as dysregulated and impulsive. The patients recovery environment is moderately stressful (score 3) due to the death of a friend by suicide and her inability to make academic progress. The patients recovery environment is supportive (score 2) as her parents have been active participants in her treatment. The patient has exhibited poor response to treatment (score 4) due to developmental pressures and life changes [that] have created episodes of turmoil or sustained distress. The patient has been constructive with treatment (score 2). The patient has been described as involved in therapy and the patient admitted to having more mood swings and a greater desire to restrict her intake. This gives the patient a composite score of 21, which is consistent with medically monitored community based services. However, due to scores of 4 on functional impairment and environmental stressors, the recommended level of care is Level Five, medically monitored residence based services, such as RTC. Furthermore, the patient qualifies for Level 5B, intermediate stay residence based services. She is highly distressed with some history of harm to self and the risk of engaging in destructive behaviors is significant in an unstructured environment. Moreover, the patient has shown recent gains while in participating in treatment in a highly structured treatment facility. Per CALOCUS, the length of stay at this level of treatment is typically no more than 60 days. In mid-April 2020, the patient was still showing mood lability and impulsivity with concerns about her transition back home. This patient has a history of multiple recent inpatient psychiatric admissions, suicidality, mood symptoms, disordered eating, and substance abuse. Given these findings as well as her continued symptoms after one month in treatment, the RTC services were and are medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were and 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 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.