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

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement and authorization and coverage for residential treatment center services. The progress notes indicate that during the period he was at the residential treatment center, the patient showed cooperative behavior and treatment progress. At times, he was unwilling to wake up when prompted, but overall, his behavior was cooperative. He was noted to play games with staff and peers and have good relationships in the treatment center. The notes do not indicate that he had any significant issues with peers. He followed all treatment programming as he was instructed. The progress notes indicate that he was open and honest in regards to his feelings about his mood and other problematic issues. He denied any past substance use. He did not have active suicidal or homicidal ideation, and he did not engage in self harm. He was eating and sleeping well. The patient did not display aggression towards peers or staff during disputed time frame. His family was involved with treatment and appeared to understand the patients needs as referenced by the progress notes which indicate their ability to aid with de-escalation. The patient did not express any symptoms of psychosis.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, providers 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 while he was not actively suicidal, he had a recent history of suicidal ideation (score = 2). Regarding functional status, the patient had mild impairment, as he had some issues with level of function due to chronic mental illness but overall showed appropriate daily functioning (score = 2). Regarding comorbidity, the patient did not have active medical problems and he had no history of substance use (score = 1). The patients recovery environment  level of stress score reflects a mildly stressful environment, as progress notes indicate that the patient had mild interpersonal conflict with family members due to his behaviors. However, the progress notes document that his relationship and family sessions were productive and were not adversarial (score = 2). The patients recovery environment  level of support score reflects that the patients parents are supportive and involved in treatment on a regular basis and that they appear to understand his needs (score = 2). The patients resilience and treatment history score is significant-moderate/equivocal, as it appears that the patient has had a response to a short period in the residential treatment center, during which period he was participating in therapy programming and not displaying any serious or disruptive symptoms (score = 2-3). The patients acceptance and engagement  child/adolescent score reflects a constructive response, as the patient participates in therapy actively and he was cooperative with consistent engagement and no apparent disruptive behavioral issues while in treatment (score = 2). The patients acceptance and engagement  parent/primary caretaker score is constructive, for the patients parents work actively and constructively with clinicians on a regular basis (score = 2). This gives the patients presentation a composite score of 15-16. This score correlates with a treatment intensity level of two which correlates with `Outpatient Services. This score is judged by the acuity of the patients symptoms and environment during the period the patient was at the residential treatment center. According to the CALOCUS, the patient would need to have a score of 23-28 in order to require treatment in a residential treatment center. Therefore, residential treatment center services were not and are not medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the services at issue were not and 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 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.