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

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement and prospective authorization and coverage for all or any of the residential treatment center (RTC) level of care provided. 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 3. The patient has significant risk of harm, due to a history of impulsivity, alcohol use, anxiety, panic attacks, and substance use. In terms of functional status, the records support a score of 3. The documentation noted moderate functional impairment due to missing and doing poorly in school as a result of her anxiety. With regard to comorbidity, the records support a score of 3. The patient had significant comorbidity, due to the presence of substance use, anxiety, panic attacks, depression, Raynauds disease, and celiac disease. 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 good relationships with her parents and brother, but significant stressors from expectations regarding school. With regard to level of support of the recovery environment, the records support a score of 3 due to good relationships with the parents and brother, but some concerns regarding limited ability to respond appropriately to the patients issues.  In terms of resiliency and treatment history, the records support a score of 3. The patient had moderate or equivocal response to treatment due to a recent hospitalization for mixing her medications with alcohol. With regard to treatment acceptance and engagement, the records support a score of 2. The patient participated in treatment. Thus, the patient has a total score of 20. In this case, the recommended level of care is medically monitored community-based services. This is inconsistent with the level of care that the patient received at the RTC. In this patients case, RTC level of care was not and is not in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the services at issue were not and are not clinically appropriate in terms of type, frequency, extent, site, and duration. The services at issue were and are 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 was not and is not medically necessary for the treatment of this patient. 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 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.