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

The patient is a female who was diagnosed with post-traumatic stress disorder, major depressive disorder, alcohol use disorder, and tobacco use disorder. She also reported use of cocaine and ecstasy. The patient reported that she was a victim of sexual assault. The patient attempted suicide and reported active suicidal ideation. She was admitted to a residential treatment center. The parent of the patient has requested reimbursement for residential treatment center services that were provided. The Health Plan denied the request and reported the services at issue were not medically necessary for the treatment of this patient. At issue in this case is whether the residential treatment center services that were provided were medically necessary for the treatment of the patients medical condition. The Child and Adolescent Level of Care Utilization System (CALOCUS), developed as a collaboration between the American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists, is a level of care assessment tool used by behavioral health managers and clinicians to support accurate level of care recommendations. The six dimensions of CALOCUS include risk of harm, functional status, comorbidity, recovery environment, resiliency and treatment history, and acceptance and engagement. For risk of harm, the patients score is 3, due to her depressed mood, anger, flashbacks, suicidal ideation and suicide attempt. The patient also reported cravings and a relapse of drug use. For functional status, the patients score is 3, due to a conflicted relationship with her family, disturbance of sleep and activity, as well as anger and distrust toward her parents. For comorbidity, the patients score is 3, due to a medical illness as evidenced by nausea and vomiting and requiring an urgent care evaluation, and a drug use relapse due to being overwhelmed with her emotional state and post-traumatic stress disorder. For recovery environmental stress, the patients score is 4, due to her parents divorce and substantial family discord. For recovery environmental support, the patients score is 4, since her parents displayed limited ability to participate in treatment. For resiliency and treatment history, the patients score is 3, due to the patients ambivalence and resistance to treatment recommendations, including medication and pursuing abstinence from alcohol. For child or adolescent treatment acceptance and engagement, the patients score is 3, due to her ambivalence, avoidance, and distrustful relationships with providers. For parent and or primary caretaker acceptance and engagement, the patients score is 2, due to the patients mother participating in family therapy. The patients composite CALOCUS score, consistent with residential treatment center level of care. Therefore, residential treatment center services that were provided were medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested services 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 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.