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 any or all of the RTC level of care services. 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 a history of suicidal ideation and self-harm, including a suicide attempt by overdosing on her fathers medications. The records noted that the patient had been rejected by a partial hospitalization program (PHP) due to safety concerns.   In terms of functional status, the records support a score of 3. The documentation noted moderate functional impairment due to social withdrawal, conflict with her mother, and a decline in school attendance and academic performance. The records noted recent gains and stabilization in functioning while participating in treatment at the RTC. With regard to comorbidity, the records support a score of 1. The patient had no comorbidity. 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 disruptions caused by the pandemic and past bullying. With regard to level of support of the recovery environment, the records support a score of 2 due to the parents active participation in treatment, including in family therapy sessions.In terms of resiliency and treatment history, the records support a score of 3. The patient had moderate or equivocal response to treatment as she experienced worsening symptoms after completing an intensive outpatient program (IOP) and continued to struggle after her inpatient hospitalization and during treatment at the RTC. With regard to treatment acceptance and engagement, the records support a score of 2. The patient demonstrated high motivation and actively participated in treatment. Thus, the patient has a total score of 18. The records support a 4 in terms of risk of harm. In this case, the recommended level of care is medically monitored residence-based services. With the elevated risk of harm noted, the patient meets CALOCUS 5b extended stay criteria.  This is consistent with the level of care that the patient received 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, all of the RTC level of care services were and are 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.