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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested reimbursement for all or any of the residential treatment center (RTC) services provided by Viewpoint Center from 3/25/20 through 4/27/20.At issue is whether any or all of the residential treatment center (RTC) services provided by Viewpoint Center from 3/25/20 through 4/27/20 were medically necessary for the patients medical condition.The Child and Adolescent Level of Care Utilization System (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 4. The patient had a serious risk of harm, due to impulsive aggression that required restraint and/or seclusion on multiple occasions at the RTC, with poor insight due to his psychosis. In terms of functional status, the records support a score of 4. The documentation noted serious impairments in judgment due to multiple instances of conflict and aggression with staff and other residents at the RTC. With regard to comorbidity, the records support a score of 3. The patient had significant comorbidity, due to reported past substance abuse which stopped in the protected setting of the RTC. In terms of level of stress of the recovery environment, the records support a score of 3. The patient had a moderately stressful environment due to disruption of patients schooling and social milieu as a result of extended time in treatment. The patient also reported social and legal issues with his father. With regard to level of support of the recovery environment, the records support a score of 2 due to mother's active involvement in treatment and treatment planning. In terms of resiliency and treatment history, the records support a score of 4. The patient had poor resiliency and/or response to treatment due to persistent symptoms despite  two prior inpatient hospitalizations and a prior stay in residential treatment. With regard to treatment acceptance and engagement, the records support a score of 4 because of the patients refusal to take medication and his denial of the need for residential treatment and denial of his illness.Thus, the patient has a total score of 24. The records support a 4 in terms of risk of harm and functional status. In this case, the recommended level of care was medically monitored residence-based services due to serious risk of harm, serious functional impairment, and a total score of over 23. This is consistent with the level of care that the patient received at the RTC. Therefore, RTC services provided by Viewpoint Center from 3/25/20 through 4/27/20 were medically necessary for the treatment of the patients medical condition. Final Result: The reviewer determined that the services at issue were 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.