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

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement for residential treatment center (RTC) level of care services.Findings:  The physician reviewer found that (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 history of suicidal ideation with plan, one near suicide attempt by overdose, and multiple self-harm behaviors by cutting with a razor and punching herself. While at the RTC, the patient continued to endorse chronic passive suicidal ideation and engaged in self-harm. In terms of functional status, the records support a score of 3. The documentation noted moderate functional impairment due to a reported lack of energy, poor sleep, concentration difficulties, and a decline in participation in activities previously enjoyed, but noted that the patient was participating in treatment during her stay at the RTC. With regard to comorbidity, the records support a score of 4. The patient had significant comorbidity, due to the presence of insomnia and gastrointestinal issues, which affected the patients depression. 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 tensions within her parents marriage and their potential alcohol overuse. With regard to level of support of the recovery environment, the records support a score of 2 due to her parents efforts to support the patient by seeking marital counseling and abstaining from alcohol use for an unspecified period of time after the patient expressed her concerns.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 insufficient progress during an inpatient psychiatric hospital stay for suicidal ideation to allow her to safely return home upon discharge.With regard to treatment acceptance and engagement, the records support a score of 2. The patient engaged in treatment, although was noted to initially struggle with a new therapist mid-way through her treatment stay. Thus, the patient has a score of 20. The records support a 4 in terms of comorbidity. In this case, the recommended level of care was medically monitored residence-based services. This is consistent with the level of care that the patient received at the RTC. Therefore, RTC level of care services were medically necessary for the treatment of this patient. Final Result: The reviewer determined that the services at issue were 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.