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 any or all of the (residential treatment center) RTC level of care provided.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 4. The patient had a serious risk of harm, due to a history suicidal ideation, self-harm by cutting, and risky online behaviors. The patient endorsed suicidal ideation with a plan and had recently written a suicide note. The patient endorsed multiple symptoms of depression and anxiety. In terms of functional status, the records support a score of 2. The documentation noted mild functional impairment due to a memory issues affecting academic progress.With regard to comorbidity, the records support a score of 3. The patient had significant comorbidity, due to the presence of sleep problems, a history of dietary restriction and binging behaviors, and partial blindness secondary to retinal detachment.In terms of level of stress of the recovery environment, the records support a score of 4. The patient had a highly stressful environment because of struggles at home, due to the patients gender fluidity and family violence, and at school, due to the patients memory problems and struggles with social skills. The patients activities were restricted due to a history of retinal detachment.With regard to level of support of the recovery environment, the records support a score of 3 due to dysfunctional patterns in the family leading to limited support. In terms of resiliency and treatment history, the records support a score of 3. The patient had moderate or equivocal resiliency and/or response to treatment due to a history of two inpatient psychiatric hospitalizations and transfer from an intensive outpatient program (IOP) to RTC due to safety concerns. The patient was noted to have failed outpatient treatment.With regard to treatment acceptance and engagement, the records support a score of 4. The patient appeared to dissociate intermittently during group sessions, struggled to take accountability for his actions, tending to blame others, and appeared to lack insight.Thus, the patient has a total score of 23. The records support a 4 in terms of risk of harm. In this case, the recommended level of care is medically monitored residence-based services. With the elevated risk of harm noted, the patient meets CALOCUS 5b extended stay criteria. This is consistent with the level of care that the patient received and is receiving at 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 level of care provided 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.