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 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 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 suicidality, impulsivity, and struggles with basic self-care and hygiene prior to admission and during the first two weeks of his RTC treatment. With regards to functional status, the records support a score of 4, which reflects serious functional impairment, due to the patients serious deterioration of interpersonal interactions, with consistent conflict or otherwise disrupted interactions with others, as well as his consistent failure to achieve self-care/hygiene at levels appropriate to age and/or developmental level. In terms of comorbidity, the records support a score of 1. The patient has no co-morbidity, due to the absence of substance abuse, developmental disorders, and medical conditions. With regards to the level of stress of the recovery environment, the records support a score of 2. The patients recovery environment was mildly stressful due to interpersonal conflict and the patient's discomfort with expectations at school and home. In terms of the level of support of the recovery environment, the records support a score of 2, which corresponds with a supportive environment, due to the patients parents' participation in treatment. With regards to resiliency and treatment history, the records support a score of 4, which reflects poor resiliency and/or response to treatment. This is due to worsening of the patients symptoms despite prior inpatient, short-term residential, and PHO/IOP treatment, as well as outpatient therapy and medication management. In terms of acceptance and engagement of the patient, the records support a score of 3. The patients score reflects that the patient was incompletely engaged, due to his struggles with participation in RTC treatment. Thus, the patient has a composite score of 20. 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. Furthermore, the patient qualified for Level 5B: Intermediate Stay Medically Monitored Residential Program, due to his history of self-harm, impulsivity, high level of distress, recent gains made in a structured setting, school difficulties and sporadic attendance, conflict with peers and parents, and lack of response to lower levels of care. Per CALOCUS, the length of stay at this level of care is up to 60 days. Accordingly, residential treatment center (RTC) services provided during the period under consideration 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.