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) 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 adolescents needing mental health treatment. Using CALOCUS, providers score patients on a scale of 1-5 using a six-pronged Dimensional Rating System. The six dimensions include: (1) risk of harm; (2) functional status; (3) medical, addictive and psychiatric comorbidity; (4) recovery environment (a. stressors and b. supports); (5) treatment and recovery history; and (6) engagement. The composite score is then used to determine the level of care needed.Applying CALOCUS, the patient was at low risk of harm (score  1) as the medical records indicate that the patient was not actively suicidal during this admission and was not a safety risk. The patient did not experience any signs of psychosis and was not aggressive toward peers. On admission, the patient reported anxiety issues as well as substance use and difficulty with focus. Patient continued to have some anxiety symptoms but rated anxiety as low. The patients overall symptom presentation appeared mild in nature. The patient demonstrated mild functional impairment (score  2) and experienced some issues with level of function due to mental illness and substance use. Overall, the patient showed appropriate daily functioning and intact activities of daily living. The patient had significant co-morbidities (score  3) given the patients history of anxiety and substance use that affected her mood. She also had kidney stones that resolved. The patients recovery environment was mildly stressful (score  2), and there was no indication of an unsafe home environment. The patients recovery environment was supportive (score  2) as family was involved in treatment on a regular basis. The patients prior treatment has yielded limited response (score  3) as the patient has undergone minimal prior outpatient treatment. The patients acceptance and engagement was described as constructive (score  2) as patient actively participated in therapy. The patient was cooperative during the disputed timeframe. The patient was compliant with staff direction on a regular basis. The patient expressed different ways she was using the coping skills learned in therapy at the RTC. The patients parents were also noted to be constructive with treatment (score  2) as they worked actively with providers on a regular basis. Her family participated in family therapy sessions and was open to discussion about their problems. This gives the patients presentation a composite score of 17, which correlates with IOP services. Therefore, the RTC services were not medically necessary for 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 upheld. 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.