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

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for Residential Treatment Center (RTC) services at a facility that treats children.The American Academy of Child and Adolescent Psychiatrys Principles of Care for Treatment of Children and Adolescents with Mental Illnesses in Residential Treatment Centers states that the best place for children and adolescents is at home with their families. 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 repeated aggressive behaviors toward his younger siblings at home prior to admission to the hospital. These behaviors led to injury on more than one occasion. Although he did not display this behavior in the structured setting of the hospital, his statements in the hospital indicate that the aggressive behavior was likely to resume when he returned home. The patient has also, more recently, behaved aggressively and required multiple holds at his current residential treatment center. With regards to functional status, the records support a score of 3, which reflects moderate functional impairment, due to the patients gains and/or stabilization in function that have been achieved while participating in treatment in a structured, protected, and/or enriched service. In terms of comorbidity, the records support a score of 3. The patient has significant co-morbidity, due to due to his autism spectrum disorder, disruptive mood dysregulation disorder, and attention-deficit/hyperactivity disorder. With regards to the level of stress of the recovery environment, the records support a score of 2. The patients recovery environment is mildly stressful due to conflict with siblings, and lengthy inpatient hospitalization, but no concerns about material resources. In terms of the level of support of the recovery environment, the records support a score of 3, which corresponds with limited support in the environment, due to difficulties in obtaining adequate resources to support the patient and his family prior to inpatient hospital admission and residential treatment center placement. 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 due to the patient's lack of response at lower levels of care, with decreased aggression in the inpatient hospital. In terms of acceptance and engagement of the patient, the records support a score of 3. The patients score reflects that the patient is incompletely engaged, due to his difficulty accepting responsibility for his past aggressive behaviors. 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 his 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. Accordingly, Residential Treatment Center (RTC) services at a facility that treats children are medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested services are 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 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.