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 provided to the patient for a 90-day program.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 2 due to a history of suicidal ideation. The patient reported suicidal ideation without a plan and ongoing distress and anxiety around school. In terms of functional status, the records support a score of 4. The documentation noted serious functional impairment due to avoidant behaviors and anxiety surrounding school. The patient was not attending school at times prior to RTC admission and continued to have significant mood symptoms and distress that impaired his functioning. He endorses continued vague suicidal ideation and high anxiety, requiring staff support and guidance. With regard to comorbidity, the records support a score of 3. The patient had significant comorbidity, due to a history of depression, anxiety, attention deficit hyperactivity disorder, obsessive compulsive disorder, somatic complaints, and concerns of avoidant restrictive food intake disorder. The patient also had ongoing speech and language difficulties.  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 the parents attempts to support the patient, but with relational challenges. With regard to level of support of the recovery environment, the records support a score of 3 due to the patient splitting time between his father and mother and having to manage two household dynamics.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 a history of multiple medication trials, and treatment at lower levels of care. With regard to treatment acceptance and engagement, the records support a score of 3. The patient continued to have challenges with food intake and the ability to use coping skills adequately.Thus, the patient has a total score of 22. The records support a 4 in terms of functional status. In this case, the recommended level of care is medically monitored residence-based services. With the functional impairment and elevated risk of harm noted, the patient meets CALOCUS 5b extended stay criteria. This is consistent with the level of care that the patient was and is receiving at the RTC. In this patients case, RTC level of care was and is in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the services at issue were and are clinically appropriate in terms of type, frequency, extent, site, and duration. The services at issue were not and are not primarily for the economic benefit of the health care service plan and subscribers or for the convenience of the patient, treating physician, or other health care provider. Therefore, services provided to the patient for a 90-day program were and are medically necessary for the 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 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.