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

Nature of Statutory Criteria/Case Summary:  The parents of an enrollee have requested reimbursement for all or any of the RTC services provided at Evolve Growth Initiatives 1/18/21 to 2/07/21.At issue is whether the all or any of the RTC services provided at Evolve Growth Initiatives from 1/18/21 to 2/07/21 were medically necessary to treat the patients medical condition as defined in Health and Safety code section 1374(a)(3)(A) set forth below. Medically necessary treatment of a mental health or substance use disorder means a service or product addressing the specific needs of that patient, for the purpose of preventing, diagnosing, or treating an illness, injury, condition, or its symptoms, including minimizing the progression of that illness, injury, condition, or its symptoms, in a manner that is all of the following: (i) in accordance with the generally accepted standards of mental health and substance use disorder care; (ii) clinically appropriate in terms of type, frequency, extent, site, and duration; (iii) 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.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. 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. Applying the CALOCUS framework, the patient met the criteria for RTC services provided at Evolve Growth Initiatives from 1/18/21 to 2/07/21.With regard to risk of harm, the records support a score of 4. The patient had a recent serious suicide attempt via overdose, as well as reported impulsivity with little insight into triggers, and a history of non-suicidal self-harm.In terms of functional status, the records support a score of 3. The documentation noted moderate functional impairment due to conflicted relationships with parents.With regard to comorbidity, the records support a score of 1. The patient had no comorbidity due to the absence of substance abuse, medical issues, and developmental disorders. 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 parents recent separation and the patients ongoing distress related to his relationships with his parents. With regard to level of support of the recovery environment, the records support a score of 2 due to his parents active participation in treatment.In terms of resiliency and treatment history, the records support a score of 3. The records noted moderate or equivocal resiliency and/or response to treatment due to the patients struggle to cope with his parents separation and to communicate his feelings to them, and instead engaged in impulsive self-harm and a suicide attempt.With regard to treatment acceptance and engagement, the records support a score of 2 due to the patients active participation in treatment.Thus, the patient has a total score of 19. Based on the patients score of 4 in terms of risk of harm, the recommended level of care is medically monitored residence-based services. This is consistent with the level of care that the patient received at the RTC. Furthermore, the patient qualifies for Level 5B: Intermediate Stay Medically Monitored Residence-Based Services, due to his history of impulsiveness and suicidal ideation. This was demonstrated by the patients distress related to his parents separation, his impulsive self-harm and his suicidal ideation, and his difficulty communicating with his parents. Per CALOCUS, the length of stay at Level 5B is up to 60 days. The patient was denied additional residential treatment after only 14 days, and his total time in residential treatment was about 35 days, or five weeks. This is well within the recommended range of treatment. Given the patients recent impulsive suicide attempt, as well as the high level of stress in his home environment due to parental conflict and separation, this length of stay was clinically appropriate. In this patients case, RTC level of care was in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the services at issue were clinically appropriate in terms of type, frequency, extent, site, and duration. The services at issue were 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, RTC services provided at Evolve Growth Initiatives from 1/18/21 to 2/07/21 were medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the services at issue were 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.