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 authorization and coverage for residential treatment center services.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 2. The patient has some risk of harm due to her history of an emergency room visit as a result of severe suicidal ideation, though there is no history of acting on these thoughts. In terms of functional status, the records support a score of 4. The patient has serious functional impairment due to behaviors that have been chronic in nature in the social and emotional realms. The patient has spent inordinate amounts of time on schoolwork and academics resulting in exhaustion, severe compromise in social relationships, and panic attacks and depression with suicidal ideation due to her obsessive compulsive disorder (OCD). The patient has also demonstrated school refusal. With regard to comorbidity, the records support a score of 3, to reflect significant co-morbidity. The patient has major comorbidity with her OCD, with significant depressive and anxiety symptoms, including panic attacks. In terms of level of stress of the recovery environment, the records support a score of 4. The patient had ongoing struggles dealing with her tendencies for perfectionism and her excessive focus on schoolwork that needs to get done, at the expense of social relationships at home and at school. With regard to the level of support of the recovery environment, the records support a score of 1. The patients family has been supportive but feels helpless in the face of the patients symptoms. In terms of resiliency and treatment history, the records support a score of 4, as the patient had poor resiliency and/or response to treatment. The patient had little positive response in outpatient therapy despite significant trials at therapy and multiple trials of medications. With regard to treatment acceptance and engagement of the patient, the records support a score of 4. The patient was non-collaborative, as she exhibited a refusal or inability to attend outpatient programs such as partial hospitalization program or intensive outpatient program treatments. The patient also discontinued her medications against advice and did not resume medication until recently, with likely limited compliance. Thus, the patient has a composite score of 22. While this composite score corresponds with a Level 4: Medically Monitored Community Based Services level of care, the patient had a score of 4 for her functional status, and this score constitutes independent criteria that would require admission to Level Five: Medically Monitored Residence-Based Services, regardless of the patients composite score. Accordingly, the requested residential treatment center services were, and are, medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the services at issue and requested services were, and are, medically necessary to treat the patient's 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.