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

Nature of Statutory Criteria/Case Summary: The patients parent has requested (1) reimbursement for all or any of the substance-related disorders, residential behavioral health level of care, child or adolescent and (2) prospective authorization and coverage for re-admittance to substance-related disorders, residential behavioral health level of care, child or adolescent.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 4. The patient had a serious risk of harm, due to a history of self-harm, active suicidal ideation, PTSD symptoms, and ongoing mental health instability.  In terms of functional status, the records support a score of 4. The documentation noted serious functional impairment due depression, anxiety, PTSD, codependence on her mother and a lack of friends. With regard to comorbidity, the records support a score of 3. The patient had significant comorbidity, due to the presence of substance abuse including opioid and cannabis use disorders, PTSD, and a history of seizures and ovarian cyst. In terms of level of stress of the recovery environment, the records support a score of 4. The patient had a very stressful environment due to codependence on her mother. With regard to level of support of the recovery environment, the records support a score of 3 due to a codependent  relationship with her mother and a lack of friends. In terms of resiliency and treatment history, the records support a score of 5. The patient had poor resiliency and/or response to treatment due to poor insight and recovery history. With regard to treatment acceptance and engagement, the records support a score of 4. The patient reported her intention to continue with cannabis use and Suboxone maintenance once discharged. Thus, the patient has a total score of 27. In this case, the recommended level of care is medically monitored residence-based services. This is consistent with the level of care the patient received at the residential treatment center, and would receive upon re-admittance. Therefore, (1) all of the substance-related disorders, residential behavioral health level of care, child or adolescent and (2) re-admittance to substance-related disorders, residential behavioral health level of care, child or adolescent 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.