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 therapeutic wilderness camp services. 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. The composite score is then used to determine the level of care needed. Applying the CALOCUS framework, this patient meets the criteria for therapeutic wilderness camp services. The patient has been at significant risk of harm (score 3) due to multiple hospitalizations for suicidal ideation and threats. The patient was recently held on a 5150 hold as a danger to herself. The patient endorses a history of self-mutilation and she was found to have texts discussing her intent to commit suicide. The patient has demonstrated serious functional impairment (score 4) given her poor hygiene, school avoidance, peer dysfunction, severe parent-child relational problems. The patient has significant comorbidities (score 3) with a history of anxiety, depression, and oppositional defiant disorder, as well as parent-child relational disorder. The patients recovery environment is moderately stressful (score 3) considering her severe ongoing conflict with her parents. The patients recovery environment is supportive (score 2). However, given the severe conflict with her parents, the patient does not view her parents as supports. The patient has exhibited poor response to treatment (score 4). The provider noted that the patient has provided little positive response in therapy despite individual sessions and medication management appointments. The patient has been incompletely engaged in treatment (score 3) as she does not appear to have responded to individual therapy and has difficulty applying skills acquired in treatment. This gives the patient a composite score of 23, which is consistent with medically monitored residence based services. Based on the CALOCUS, these services can be provided in a wilderness setting as long as they provide adequate clinical and support services, crisis stabilization and prevention services and an appropriate care environment. Based on the available documentation, the patients current RTC provides medically monitored residence based services consistent with the CALOCUS requirements. Given these findings, the therapeutic wilderness camp services were and are medically necessary for 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 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.