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

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for residential treatment center (RTC) level of care services at a closed and secure facility.The American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) provides a reliable framework for determining the appropriate level of care for children needing mental health treatment. In this case, in terms of risk of harm, the records support a score of 4, which corresponds with serious risk of harm. With regards to functional status, the records support a score of 4, which reflects serious functional impairment, due to the patients social withdrawal, difficulties with school and academic performance, and impulsivity. In terms of comorbidity, the records support a score of 3. With regards to the level of stress of the recovery environment, the records support a score of 3. In terms of the level of support of the recovery environment, the records support a score of 2, which corresponds with a supportive environment, due to the patients fathers active participation in treatment planning. With regards to resiliency and treatment history, the records support a score of 5, which reflects negligible resiliency and/or response to treatment. In terms of acceptance and engagement of the patient, the records support a score of 4. The patients score reflects that the patient is unengaged, due to their refusal to take medication and eat meals, minimal participation in groups, and their suicide attempt during inpatient hospitalization. Thus, the patient has a composite score of 25. Using the CALOCUS level of care determination decision tree, the recommended level of care is Level 5: Medically Monitored Residential Services. Furthermore, the patient is scored at Level 5C: Long-Term Medically Monitored Residential Programs, due to minimal past response to treatment and an inability to maintain any gains achieved outside an intensive and highly structured setting. CALOCUS Supplemental Criteria for Residential Services state that at this level of care, the length of stay will vary from two months to a year. In contrast, the CALOCUS level of care determination decision tree requires a score of 28 or more to meet criteria for Level Six: Medically Managed Residence-Based Services, which includes locked residential programs. Accordingly, the patients symptoms do not meet this level of severity. Therefore, residential treatment center (RTC) level of care services at a closed and secure facility are not medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested services 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, 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.