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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for residential treatment center (RTC) 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. Using CALOCUS, providers 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.This patient presents with low risk of harm (score - 1) as the patient has not been passively or actively suicidal. The records document that she was not experiencing any suicidal or homicidal ideation or psychosis. The patient has mild functional impairment (score - 2) due to symptoms of her eating disorder. There is documentation of minor comorbidities (score - 2) as the patient has some intermittent abnormal vitals, without any chronic medical issues. She had intermittent issues with her blood pressure and pulse they were not significant in nature. She also has some intermittent cannabis use that does not appear to have an adverse effect on her functioning or the presenting problem. The patients recovery environment is mildly stressful (score - 2) as the records did mention a stressful home environment in relation to the patients history of continued relational issues with her family due to her eating disorder behaviors. The patients home environment is safe and stable. The patients recovery environment is supportive (score - 2) as her family is actively involved in regular treatment activities. The patient has demonstrated limited response to treatment (score - 3) due to positive treatment successes according to supplied treatment records that indicate continued weight gain. She continues to struggle with eating disorder behaviors but is cooperative and treatment and is honest with her maladaptive behaviors. The patient has been constructive in treatment (score - 2) as she has participated in therapy. She has been open with her treatment team in terms of her continued eating disorder behaviors while she was at home. The progress notes indicate the patient has steadily gained weight during treatment, she was within her goal weight range. The patients parent has been constructive in treatment (score - 2) and is noted to work with the patients providers. This gives the patients presentation a composite score of 16, which correlates with intensive outpatient services. Therefore, the requested RTC services are not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested services are 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.