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

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement 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 had some risk of harm due to ongoing severe family conflicts, anxiety and severe obsessive compulsive disease (OCD), and vulnerability for harm towards herself, though she had no imminent stated plans. In terms of functional status, the records support a score of 4. The patient had serious functional impairment that was chronic in nature and resulted in severe compromise of functioning at home. With regard to comorbidity, the records support a score of 2, to reflect minor co-morbidity. The patient had severe OCD, with depressive and anxiety symptoms. In terms of level of stress of the recovery environment, the records support a score of 4, which corresponds with a highly stressful environment. The patient had ongoing struggles dealing with contamination fears, and these struggles resulted in an avoidance of showers and food and an avoidance of anything that related to her mother. The patient also had ongoing severe family tensions and conflicts. With regard to the level of support of the recovery environment, the records support a score of 3, which corresponds with limited support in the environment. The patients parents each appeared to have their own conflictual dynamics with the patient. 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 appeared to have little positive response to treatment prior to residential treatment, and she needed the residential level of care to provide structure and routine as well as staff to encourage exposure and response prevention (ERP). With regard to treatment acceptance and engagement of the patient, the records support a score of 3. The patient was incompletely engaged, as she appeared to continue to struggle while at the residential level of care with regards to utilizing ERP skills, and she needed staff support. 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 residential treatment center services at issue were medically necessary to treat the patients condition.Final Result: The reviewer determined that the services at issue were medically necessary to treat the patient's 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.