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) provided by Evolve Treatment Centers. 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 3. The patient had a significant risk of harm, due to a recent episode of tying a belt around his neck, which he minimized as attention seeking behavior rather than a suicide attempt, along with a history of poor impulse control, reactivity, anger escalations, threats of self-harm, and aggressive outbursts with threats of property destruction.In terms of functional status, the records support a score of 4. The documentation noted serious functional impairment due to challenges with making and keeping friends, keeping up with schoolwork, and maintaining family relationships due to verbal and physical aggression. The patient had a history of threatening suicide and a self-harm incident by hanging himself with a belt.  With regard to comorbidity, the records support a score of 3. The patient had significant comorbidity, due to the presence of major depressive disorder, generalized anxiety disorder, attention deficit hyperactivity disorder, and parent-child relational problem.  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 a disruption of the family and social milieu as a result of his parents divorce and limited ability for setting boundaries.With regard to level of support of the recovery environment, the records support a score of 3 due to his parents limited ability to respond appropriately to his needs and difficulties setting limits and providing appropriate support for the patient. 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 limited response despite significant medication trials along with inpatient and outpatient therapy. With regard to treatment acceptance and engagement, the records support a score of 3. The patient continued to minimize issues while at the RTC, continually requesting information about the length of treatment, and appearing to have limited engagement in treatment.Thus, the patient has a total score of 23. The records support a 4 in terms of functional status. In this case, the recommended level of care is medically monitored residence-based services. With the functional impairment noted, the patient meets CALOCUS 5b extended stay criteria.  This is consistent with the level of care that the patient was and is receiving at the RTC. In this patients case, RTC level of care was and is in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the services at issue were and are clinically appropriate in terms of type, frequency, extent, site, and duration. The services at issue were not and 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, RTC services provided by Evolve Treatment Centers were and are medically necessary for the 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 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.