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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) services. 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. The patient had some risk of harm, due to a history of some self-harm and two or three suicidal gestures. The records noted that in a recent impulsive overdose attempt, the patient only took one to two pills, and did not report ongoing suicidal ideation with plan afterwards.   In terms of functional status, the records support a score of 3. The documentation noted moderate functional impairment as the patient was able to do activities of daily living and participate in school.   With regard to comorbidity, the records support a score of 2. The patient had significant comorbidity, due to the presence of depressive symptoms, anxiety, attention deficit hyperactivity disorder (ADHD), and hyperthyroidism. 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 familial conflicts. With regard to level of support of the recovery environment, the records support a score of 2 due to their parents efforts to arrange treatment for patient and their participation in treatment. In terms of resiliency and treatment history, the records support a score of 3. The patient had moderate or equivocal response to treatment and recovery management due to a limited response to a history of mental health treatment, including outpatient psychiatry. With regard to treatment acceptance and engagement, the records support a score of 2. The patient appeared to be participating in the RTC program without safety concerns. Thus, the patient has a total score of 17. In this case, the recommended level of care is high intensity community-based services. This is inconsistent with the level of care that the patient received at the RTC. In this patients case, RTC level of care was not and is not in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the services at issue were not and are not clinically appropriate in terms of type, frequency, extent, site, and duration. The services at issue were and are 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, RTC services were not and are not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the services at issue were not and are 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 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.