Appeal type: Medical Necessity
Decision: Overturned 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. Findings:  The physician reviewer found that (CALOCUS) provides a framework for determining the clinically appropriate level of care for a child or adolescent in mental health treatment. With regard to risk of harm, the records support a score of 3. The patient had a significant risk of harm, due to history of multiple suicide attempts, self-harm, and high-risk behavior.In terms of functional status, the records support a score of 3. The documentation noted moderate functional impairment due to not meeting expected developmental milestones, not attending school, and engaging in high-risk behavior.With regard to comorbidity, the records support a score of 3. The patient had significant comorbidity, due to the presence of major depressive disorder, attention deficit hyperactivity disorder, substance abuse related disorders, and generalized anxiety disorder. In terms of level of stress of the recovery environment, the records support a score of 4. The patient had a highly stressful environment due to a conflictual relationship with her parents. With regard to level of support of the recovery environment, the records support a score of 3 due to the patients parents being divorced and the patient having a conflictual relationship with both parents. In terms of resiliency and treatment history, the records support a score of 4. The patient had a poor response to treatment and recovery management as she had a history of multiple hospitalization and appeared to have failed treatment at lower levels of care.  With regard to treatment acceptance and engagement, the records support a score of 3. The patient demonstrated obstructive engagement as she continued having difficulties with self-harm while at the RTC.Thus, the patient has a total score of 23. In this case, the recommended level of care is medically monitored residence-based services. This is consistent with the level of care that the patient received and is receiving at the RTC. In this patients case, RTC level of care was and is in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the services at issue were and are clinically appropriate in terms of type, frequency, extent, site, and duration. The services at issue were not and are not 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 services were and are medically necessary for treatment of the patients mental health or substance use disorder.Final Result: The reviewer determined that the services at issue were and 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 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.