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 residential treatment center (RTC) services provided by Renewed Hope Ranch for 4 to 6 months. 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 a history of three hospitalizations related to suicidal ideation and suicide attempts, including one episode requiring intubation, and a history of impulsive and reactive behaviors. The patient attempted to self-harm while hospitalized and continued to endorse active suicidal ideation at the RTC.In terms of functional status, the records support a score of 4. The documentation noted serious functional impairment due to the patients nonparticipation in school and poor and conflictual relationships with family and peers.With regard to comorbidity, the records support a score of 4. The patient had major comorbidity, due to diagnoses of generalized anxiety disorder, major depressive disorder, possible post-traumatic stress disorder, and parent-child relational problems. The patients psychiatric symptoms impaired her functioning and seriously impaired her recovery from depression and suicidal tendencies.In terms of level of stress of the recovery environment, the records support a score of 4. The patient had a highly stressful environment due to conflictual relationships with family members. With regard to level of support of the recovery environment, the records support a score of 3 due to a home environment fraught with conflicts and tumultuous dynamics, although the patients mother was actively participating in therapy.In terms of resiliency and treatment history, the records support a score of 4. The patient has poor response to treatment and recovery management due to a history of multiple hospitalizations. With regard to treatment acceptance and engagement, the records support a score of 3. The patient appears to have limited motivation and ingrained maladaptive interpersonal interactions, was noncompliant with outpatient treatment over Zoom, and remains noncompliant with medications. Thus, the patient has a total score of 26. The records support a 4 in terms of risk of harm, functional status, and comorbidity. In this case, the recommended level of care is medically monitored residence-based services. With the elevated risk of harm, functional impairment, and comorbidity 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, services provided by Renewed Hope Ranch for 4 to 6 months, 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.