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

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement for all or any residential treatment center (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 significant impulsivity, with poor judgment and insight, that significantly endangered himself. The records noted that the patient impulsively eloped and attempted to jump in front of a car. The patient continued to report suicidal ideation with intent. The patient was unable to contract for safely and at discharge was taken to the hospital.  In terms of functional status, the records support a score of 4. The documentation noted serious functional impairment due to serious deterioration of interpersonal interactions with consistent conflict or otherwise disrupted interactions with others, including impulsive or abusive behaviors. The records noted episodes of irritability and temper outbursts and a deterioration in academic work. With regard to comorbidity, the records support a score of 1. The patient did not have comorbidities. 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 a history of assault. With regard to level of support of the recovery environment, the records support a score of 2 due to his mothers participation in 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 as he continued to experience suicidal ideation with intent and plan along with significant distress and dissociative symptoms despite previous psychiatric hospitalizations and a recent RTC stay. With regard to treatment acceptance and engagement, the records support a score of 3. The patient participated in treatment but also impulsively ran away when suicidal and had difficulty implementing a safety plan. 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. This is consistent with the level of care that the patient received at the RTC. 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 level of care services were medically necessary for the treatment of this patient. 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.