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

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement for residential treatment center (RTC) services. The main focus of the patients treatment at the RTC was the patients eating disorder behaviors. The patient had gained approximately 7 pounds from the date of admission up to his receipt of the services at issue. He had displayed intermittent struggles with eating disorder behaviors, but he was noted to eat his meals as planned by the dietitian. The patient was gaining weight appropriately. During the disputed dates at issue that followed, the patient showed cooperative behavior and treatment progress. He behaved appropriately on passes. The patient displayed no issues or adverse behaviors with peers or staff. On the few occasions that the patient did exhibit defiant behaviors, he was able to follow treatment programming as instructed. The patient was open and honest regarding his feelings about his mood, family relationships, eating disorder issues, and other problematic issues. He did not have active suicidal or homicidal ideation or psychosis. The patient did not display any significant mood symptoms or psychosis. His family was involved with treatment and appeared to understand the patients needs by providing emotional support and assisting with meal planning.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, treaters 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. Regarding the six CALOCUS dimensions, the patient displayed no active or significant risk of harm (score = 1). Regarding functional status, the patient had some issues with his level of function due to chronic mental illness, but overall the patient showed appropriate daily functioning including school progress in treatment and prior to treatment at the RTC (score = 2). Regarding medical, addictive and psychiatric comorbidity, the patient did not have active medical problems, but he had some lab abnormalities in malnutrition. There was no indication of any active substance use (score = 2). The patients level of stress was considered mild and his family sessions were productive and not adversarial (score = 2). Regarding the patients recovery environment and supports, the patients family was involved in treatment on a regular basis and appeared to understand his needs. There was no indication of an unsafe home environment (score = 2). Regarding resiliency and treatment history, the patient had a positive response to a short period in the RTC and had gained weight appropriately. He was participating in therapy programming and was not displaying any serious disruptive behaviors while in treatment (score = 3). Regarding engagement, the patient participated in therapy actively and was cooperative with consistent engagement and no apparent disruptive behavioral issues (score = 2). The patients parents appeared to take a constructive position in support of treatment with active engagement in therapy (score = 2).This gives the patients presentation a composite CALOCUS score of 16. This score indicates a treatment intensity level of three, which correlates with the Intensive Outpatient Services level of care. This score is judged by the acuity of the patients symptoms and environment during the period under dispute. Accordingly, the residential treatment center (RTC) services at issue were not medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the services at issue were 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.