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

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement and prospective 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. Applying the CALOCUS to this patients clinical presentation, the RTC services were not and are not medically necessary. The patient has been at a low risk of harm (score 1). The medical records indicate that the patient was not actively suicidal, has not engaged in self-harm, and there is no report of self-harm risk. The patient has shown mild functional impairment (score 2) as the patient has experienced issues due to mental illness and relationship with family. The records state that he has responded well to redirection at the RTC. The patient has not demonstrated any severe behavioral issues or violent outbursts. The patient does not have any reported history of substance use or active medical problems (score 1). The patients recovery environment is mildly stressful (score 2) as the patient was noted to have good relationship with his grandparents and father, but issues with the relationship he has with his mother. The patients recovery environment is supportive (score 2) as the patients parents are involved in treatment as are his grandparents. The patients treatment history does not include outpatient care prior to admission (score 3) and the records suggest he has responded to a short period in the RTC as demonstrated by his minimal symptoms, cooperative behavior, and lack of aggression. The patient has been constructive in treatment (score 2) as he participates in therapy and openly discusses his problems. He has been cooperative in treatment and compliant with taking medications as prescribed. While in the RTC, the patient was described as respectful towards staff. The patients parent has been constructive (score 2) as the patients father works actively and constructively with providers. This gives the patients presentation a composite score of 15 which correlates with intensive outpatient services. Accordingly, the patient was and is a candidate for treatment in a less restrictive treatment setting. Thus, the RTC services were not and are not medically necessary.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