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

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement for psychiatric residential treatment center 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 children needing mental health treatment. In this case, in terms of risk of harm, the records support a score of 4, which corresponds with serious risk of harm. This is due to the patients recent excessive substance use, risky sexual behaviors, impulsivity and poor choices. With regards to functional status, the records support a score of 3, which reflects moderate functional impairment, due to the patients conflict with her mother, missing school, and recent stabilization in the structured setting of the residential treatment center. In terms of comorbidity, the records support a score of 3, which corresponds with significant co-morbidity. This is due to the presence of both substance abuse and mental illness. With regards to the level of stress of the recovery environment, the records support a score of 3. The patients recovery environment was moderately stressful due to the patients mother's health issues, which affect the family/social milieu. In terms of the level of support of the recovery environment, the records support a score of 3, which corresponds with limited support in environment, due in part to the patients mother's difficulty participating consistently in the patient's treatment. With regards to resiliency and treatment history, the records support a score of 3, which reflects moderate or equivocal resiliency and/or response to treatment. This is because the patient was able to transition successfully to the residential treatment center and make progress in a highly structured setting, with moderate support. In terms of acceptance and engagement of the patient, the records support a score of 2. The patients score reflects that the patient had constructive engagement, due to her active participation in treatment. Thus, the patient has a composite score of 21. While this composite score corresponds with a Level 4: Medically Monitored Community Based Services level of care, the patient had a score of 4 for her risk of harm, and this score constitutes independent criteria that would require admission to Level Five: Medically Monitored Residence-Based Services, regardless of the patients composite score. Furthermore, the patient qualified for Level 5B: Intermediate Stay Medically Monitored Residential Program, due to her co-occurring substance abuse and mental health disorders and her recent gains made in a structured and protected setting. Per CALOCUS, the length of stay at this level of care can last up to 60 days. Accordingly, the psychiatric residential treatment center services at issue were medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the services at issue were medically necessary to treat the patients medical condition. Therefore, the Health Plans denial should be overturned.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.