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

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement for residential treatment center (RTC) level of care. 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. Findings:  The physician reviewer found that With regard to risk of harm, the records support a score of 3. The patient had significant risk of harm, due to a history of self-harm with scissors, passive suicidal ideation, laxative abuse, purging, and struggles to maintain adequate nutrition.In terms of functional status, the records support a score of 3. The documentation noted moderate functional impairment due to difficulty communicating with family, with gains made in eating patterns and coping skills while in the structured and supportive setting of the RTC. With regard to comorbidity, the records support a score of 3. The patient had significant comorbidity, due to physical complaints such as gas pain, nausea, and constipation, which may have been worsened by the patients disordered eating, and in turn made it more difficult for the patient to adhere to her food plan. The records noted that the patients weight was below target, but not in a dangerously low range requiring constant medical monitoring. In terms of level of stress of the recovery environment, the records support a score of 2. The patient had a mildly stressful environment due to some struggles by the family to respond to the patients disordered eating and body image issues. With regard to level of support of the recovery environment, the records support a score of 2 due to the parents active participation in treatment. In terms of resiliency and treatment history, the records support a score of 3. The patient had moderate or equivocal resiliency and/or response to treatment, due to her continued struggles with disordered eating despite engaging in several months of outpatient treatment and nutrition support. With regard to treatment acceptance and engagement, the records support a score of 3. The patient demonstrated incomplete engagement in treatment as she was complying with her meal plan but her motivation varied. Thus, the patient has a total score of 19. In this case, the recommended level of care is high intensity community-based services. This is inconsistent with the level of care that the patient received at the RTC. In this patients case, RTC level of care was not in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the services at issue were not clinically appropriate in terms of type, frequency, extent, site, and duration. The services at issue were 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 level of care was not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the services at issue were not 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.