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 all or any of the residential treatment center (RTC) level of care. 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 4. The patient had a serious risk of harm, due to several recent suicide attempts, chronic suicidal ideation, and a history of impulsivity. In terms of functional status, the records support a score of 4. The documentation noted serious functional impairment due to difficulty with self-care and struggles with eating, academic struggles, and conflict with family. With regard to comorbidity, the records support a score of 2. The patient had minor comorbidity, due to past substance abuse.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 family conflict. With regard to level of support of the recovery environment, the records support a score of 2 due to the parents involvement in the patients treatment and treatment planning.In terms of resiliency and treatment history, the records support a score of 4. The patient had poor response to treatment and recovery management due to the persistence of suicidal ideation, disordered eating, and mood and anxiety symptoms despite several courses of treatment at multiple levels of care, including intensive outpatient program (IOP), partial hospitalization program (PHP), and residential and inpatient treatment. With regard to treatment acceptance and engagement, the records support a score of 2. The patient demonstrated constructive participation in her treatment. Thus, the patient has a total score of 21. The records support a 4 in terms of risk of harm and functional status. In this case, the recommended level of care is medically monitored residence-based services. With the functional impairment and elevated risk of harm noted, the patient meets CALOCUS 5b extended stay criteria. This is consistent with the level of care that the patient was and is receiving at the 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 was and is 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.