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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for residential treatment center (RTC) services provided and prospective authorization and coverage for RTC services for 45 days after discharge from the hospital. 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 presented with some risk of harm (score 2) as the patient was not actively suicidal at any time but did have a history of suicidal ideation and overdose. Specifically, the records did not report any active suicidal or homicidal ideation or psychosis. The patients functional status has been moderately impaired (score 3) given continued struggles with behavioral health issues, but overall appropriate daily functioning and intact activities of daily living. The patient presents with no comorbidity (score 1) given the absence of active medical problems or substance use issues. The patient reported depression due to bladder control issues. On admission, the patient noted feelings of depression due to being bullied online and some anxiety symptoms. The patients recovery environment is mildly stressful (score 2) as the patient was noted to have family sessions that were productive and not adversarial. Further, the patients recovery environment is supportive (score 2) as the parents are involved in the patients treatment on a regular basis and have demonstrated an understanding of the patients needs. The patient has demonstrated limited response to prior treatment (score 3) with a history of treatment, but on admission was not receiving any noted outpatient care. The patients acceptance and engagement in treatment was initially limited, but improved over time (score 2). The patient was described as cooperative and followed treatment programming as instructed. The progress notes indicate the patient was open regarding mood, family relationships, and other problematic issues. The patients parents have been constructive in treatment (score 2), as they have worked actively and constructively with providers on a regular basis. The progress notes document the parents ability to aid the patient with emotional support as well as provide motivation to participate in family therapy. This gives the patients presentation a composite score of 17. This score correlates with a treatment intensity level of three, which is consistent with IOP level of care services. Overall, the records do not support that the requires the intensity and supervision that is provided at the RTC level of care. Accordingly, the RTC services provided, and RTC services for 45 days after discharge from the hospital, were not and are not medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the services at issue were not and 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.