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. 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) developmental, medical, substance use 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 the CALOCUS guidelines, this patient meets the criteria for RTC level of care services. The patient has been at serious risk of harm (score 4) due to significant impulsivity, poor judgment and insight. The provider noted that the patients behavioral issues are significantly endangering to herself and others. The patient has shown moderate functional impairment (score 3) given the conflict with her parents, and recent gains made in a structured setting. The patient has no significant comorbidities (score 1) as the records do not report any substance abuse, developmental disorders, or medical issues. The patients recovery environment is moderately stressful (score 3) due to school difficulties with bullying by peers at school and online. The patients environment is supportive (score 2) as her parents have actively participated in her treatment. The patient has exhibited poor response to treatment (score 4) with continued symptoms despite multiple treatment attempts at higher levels of care. The patient has been incompletely engaged in treatment (score 3) as the records report difficulty accepting responsibility for her behaviors and minimization of symptoms. This gives the patient a composite score of 20, which is consistent with medically monitored community based services. However, per the CALOCUS determination grid, the appropriate level of care is level 5, medically monitored residence based services as the patient has a score of 4 on risk of harm. Further, the patient meets the criteria for level 5B intermediate stay medically monitored residential programs given the presence of suicidal or homicidal ideation with some ambivalence. The patient remains ambivalent about treatment and takes limited responsibility for her actions. Per CALOCUS, the recommended length of stay for this type of facility is up to 60 days. Given these findings, RTC level of care services were and are medically necessary for treatment of this patient.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 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.