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

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for residential treatment center (RTC) services provided at a facility that treats children. The patient was initially admitted to the inpatient acute psychiatric hospital setting due to aggression towards his family members. Inpatient psychiatric records indicate that the patients behavior quickly stabilized. He was noted to be cooperative in therapy, was not aggressive towards his peers, and did not engage in self-harm. The clinical recommendation was for the patient to be discharged to home with community-based treatment. The progress notes from the inpatient setting indicate the patient was not experiencing suicidal or homicidal ideation or psychosis. He did not have any substance use issues or medical problems that were affecting his psychiatric presentation. His family was engaged in treatment and progress notes indicated that family visits went well. The progress notes indicate the patient was not showing aggressive behavior at school. It appears that his aggressive behavior was limited to the home setting, as this behavior was absent from the acute inpatient psychiatric hospital setting. The recent records indicate the patient had intermittent behavioral problems that appeared consistent with his psychiatric diagnoses. He did not have any significant behavioral issues and his sleep and appetite were noted to be normal.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. Applying the CALOCUS criteria, this patient presents with some risk of harm (score 2) as the medical records indicate that he has not been passively or actively suicidal. He has a history of aggression towards family, but the records do not document any aggression in school or in the inpatient setting. The patient demonstrates mild functional impairment (score 2) as the progress notes indicate significant improvement after a period of deterioration. He has demonstrated age appropriate activities of daily living. Records indicate that the patient was not experiencing aggression in the school setting. The patient presents with no co-morbidity (score 1) given the absence of medical problems or history of substance use. The patients recovery environment is mildly stressful (score 2) as the records document the patient has a history of aggression with his siblings. The patients home environment is safe and stable. The patients recovery environmentis supportive (score 2) as the patients mother is actively involved in regular treatment activities. The patient has shown limited response to prior treatment (score 3), with a lack of progress prior to the inpatient admission. The patient demonstrated some positive treatment success during the several weeks in the acute inpatient psychiatric setting. The patient has been constructive in treatment (score 2) as he is noted to actively participate in therapy. The patients parents have also been constructive in treatment (score 2) and work actively and constructively with the patients providers. This gives the patients presentation a composite score of 16, which correlates with intensive outpatient services. Given these findings, the records do not support the RTC services provided at a facility that treats children as medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.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.