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

Nature of Statutory Criteria/Case Summary:The patient has been diagnosed with major depressive disorder, attention deficit/hyperactivity disorder, and posttraumatic stress disorder. The patient was admitted to a residential treatment center (RTC). The patient endorsed difficulties in school and had previously expressed suicidal ideation without a plan or attempts. The patient was reported to have made good progress. The records noted that she was cooperative and had an appropriate affect. Her risk of self-harm was noted to be low, and her risk of harming others was also low. Her suicide risk was rate rated as low. Her progress was noted to be good, and her suicide risk was noted to be low.  The patient showed appropriate affect and was adherent to her medications. Her suicide risk was rated to be low.  The patients treatment progress was noted to be good. She endorsed being worried about grades and reported a fear of being bullied when she returns home. Her suicide and self-harm risk were both rated to be low. The patient was noted to have an appropriate and euthymic affect and a low suicide risk. The patients parent has requested reimbursement for RTC level of services. The Health Plan denied the request and reported the services at issue were not medically necessary for the treatment of this patient. At issue in this case is whether RTC level of services provided were medically necessary for treatment of the patients medical condition. The patient was initially admitted to a RTC due to depression, attention deficit/hyperactivity disorder, and posttraumatic stress disorder. During treatment, the patient was noted to show cooperative behaviors. The patient did not have any noted behavioral issues during treatment. She showed insight into her need for continued treatment. The patient was cooperative with staff and peers and cooperated in therapy. Suicidal or homicidal ideation or psychosis were not reported during treatment. The patient did not display aggression toward peers or staff. Her family was involved in her treatment. She did not have medical problems and had a safe living environment to return to. The Child and Adolescent Level of Care Utilization System (CALOCUS), developed as a collaboration between the American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists, is a level of care assessment tool used by behavioral health managers and clinicians to support accurate level of care recommendations. The six dimensions of CALOCUS include risk of harm, functional status, comorbidity, recovery environment, resiliency and treatment history, and acceptance and engagement. For risk of harm, the patients score is 1, due to no suicidal ideation and a documented low risk for suicidal and self-harm behavior. For functional status, the patients score is 2, due to a reported conflict with her peers and difficulty in school. She showed a significant improvement in function following a period of deterioration. For comorbidity, the patients score is 1, due to no medical problems or substance use. For recovery environmentlevel of stress, the patients score is 2. The records did not mention a stressful home environment, although the patient had a strained relationship with her mother who did not live in the home. For recovery environment level of support, the patients score is 2, due to the patients father participating in her treatment. For resiliency and treatment history, the patients score is 2, due to reported good treatment progress, cooperation in treatment, and medication adherence. For acceptance and engagement of the adolescent, the patients score is 2, due to her participation in therapy. Her insight and judgment were noted to be fair throughout treatment. For acceptance and engagement of the parent, the score is 2, due to the patients father participating in her treatment. The composite CALOCUS score is 14, which correlates with outpatient services. The medical evidence does not support the services at issue in this clinical setting. Therefore, RTC level of services were not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested services 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.