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

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement and prospective authorization and coverage for residential treatment center 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, 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. Regarding the six CALOCUS dimensions, the patient had some potential for risk of harm, for she is noted to have had a history of serious harm to others and suicidal ideation and covert preparation for self-harm or suicide (score = 3). Regarding functional status, the patient had been neglecting her ADLs and had a history of a previous shutdown (score = 4). Regarding comorbidity, the patient has a significant comorbidity, sensory integration disorder (score = 3). The patients recovery environment  level of stress score reflects a highly stressful environment (score = 4). The patients recovery environment  level of support score reflects that the patients recovery support was limited (score = 4). The patients resilience and treatment history score (score = 4) and her acceptance and engagement  child/adolescent score (score = 4) were adversely affected by her non-adherence and repeated rejection of therapists, along with multiple relapses. The patients acceptance and engagement  parent/primary caretaker score appeared destructive (score = 4) due to their competition. This represents a composite CALOCUS score of 26 at the time of admission to the RTC. The patient therefore met CALOCUS criteria on the date of admission to residential treatment center services. After treatment, however, the patient no longer met CALOCUS criteria for a continued RTC stay. The CALOCUS score after admission was 18, with marked improvement in the patient's daily functioning and engagement and acceptance of treatment; especially her willingness to continue Lexapro, which had improved her mood and anxiety. The patients family appeared much more prepared to continue therapy and to be supportive. Therefore, the RTC services provided during the patients admission were medically necessary for treatment of the patients medical condition. The RTC services following the patients 12th month of admission to the RTC were not, and are not, medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that some of requested services were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially 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.