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 mental health services. The American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) provides a reliable framework for determining the appropriate level of care for adolescents needing mental health treatment. Using CALOCUS, providers score patients on a scale of 1-5 using a six-pronged Dimensional Rating System. The six dimensions include: (1) risk of harm; (2) functional status; (3) medical, addictive and psychiatric comorbidity; (4) recovery environment (a. stressors and b. supports); (5) treatment and recovery history; and (6) engagement. The composite score is then used to determine the level of care needed.Based on CALOCUS criteria, this patient meets the criteria for residential mental health treatment. The patient is at serious risk of harm to others (score 4) as evidenced by the patients recent excessive alcohol use, suicidal ideation, and self-harm. The patient has demonstrated moderate functional impairment (score 3) due to conflicted family relationships, disordered eating, and recent gains in functioning in a highly structured setting. The patient has significant comorbidities (score 3) due to the combination of serious substance use as well as depression, disordered eating, and anxiety. The patients recovery environment is highly stressful (score 4) as evidenced by difficulty avoiding substance use in the community as well as family conflict. The patients recovery environment provides limited support (score 3) due to parental difficulties in making changes during treatment. The patient has shown limited resiliency and response to treatment (score 3) due to a lack of success with outpatient therapy and moderate progress in a highly structured setting. The patient has been constructive in treatment (score 2) due to the patients ability to passively cooperate with treatment. The patients parents have been constructive with the patients treatment (score 2) and have participated in her treatment program. This gives the patient a composite score of 24, which meets the criteria for medically monitored or medically managed residence based services, such as residential mental health level of care. Considering the patients score of 4 on Dimension 1, and scores of 4 and 3 on Dimensions 4a and 4b, respectively, the appropriate level of care is Level 5, non-secure 24-hour services with psychiatric monitoring. Given these findings, the residential mental health services were and are medically necessary for 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 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.