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

Nature of Statutory Criteria/Case Summary:  The parents of an enrollee has requested reimbursement for residential treatment center (RTC) services provided by Tarzana Vanalden from 8/20/21 through 8/23/21.At issue is whether RTC services provided by Tarzana Vanalden from 8/20/21 through 8/23/21 were medically necessary to treat the patients medical condition as defined in Health and Safety code section 1374(a)(3)(A) set forth below. Medically necessary treatment of a mental health or substance use disorder means a service or product addressing the specific needs of that patient, for the purpose of preventing, diagnosing, or treating an illness, injury, condition, or its symptoms, including minimizing the progression of that illness, injury, condition, or its symptoms, in a manner that is all of the following: (i) in accordance with the generally accepted standards of mental health and substance use disorder care; (ii) clinically appropriate in terms of type, frequency, extent, site, and duration; (iii) 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.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. 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. With regard to risk of harm, the records support a score of 3. The patient had significant risk given ongoing reported suicidal ideation, although not mentioning specific plans. There is a history of extreme distress and/or a history of suicidal behavior.In terms of functional status, the records support a score of 4. The patient had ongoing suicidal ideation, although with no specific plans reported. The patient continued to have multiple depressive symptoms, and her ambivalent feelings about her family and family dynamics continued to be quite difficult. The patients familys ability to safety plan also continued to be challenging. The patient had debilitating interpersonal functioning. With regard to comorbidity, the records support a score of 3. The patient had a history of substance use that had significant impact on the presenting condition. The patient appeared to still have some substance use urges. The patients psychiatric signs and symptoms continued to appear in the absence of stress, were moderately debilitating, and adversely affected the patients condition. In terms of level of stress of the recovery environment, the records support a score of 3. The patients recovery environment had concerns for exposure to substance abuse and its effects. There is also a history of parent child relationship issues that contribute to the stress in the recovery environment.With regard to level of support of the recovery environment, the records support a score of 3. The patients parents were overwhelmed despite efforts. The patients family had limited ability to respond appropriately to the patients developmental needs and/or problems. In terms of resiliency and treatment history, the records support a score of 4. The patient had limited response to services despite significant amount of treatment. The patient demonstrated frequent evidence of innate vulnerability under stress and difficulty resuming progress toward expected developmental level. The patient had not achieved completed remission of symptoms or optimal control of symptoms with previous treatment even, with intensive and/or repeated exposure to treatment.With regard to treatment acceptance and engagement, the records support a score of 3. The patient demonstrated ambivalence, avoidance, or distrust in her relationships with clinicians and other care providers. Overall, the patient acknowledged existence of problem, but appeared to have challenges with responsibility for development and resolution of the problem. These findings give the patient a composite score of 23. Per records, the patient continued to have significant suicidal ideation urges and distress in general from 8/20/21 through 8/23/21. The patients limited progress despite a history of significant treatment points to innate fragility and vulnerability. The patient was at risk of decompensation and required RTC level of care for safety and stabilization. In this patients case, RTC level of care was in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the services at issue were clinically appropriate in terms of type, frequency, extent, site, and duration. The services at issue were 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 services provided by Tarzana Vanalden from 8/20/21 through 8/23/21 were medically necessary for treatment of the patients medical condition.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.