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

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for acute inpatient treatment pending residential treatment center placement.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 3, which reflects moderate functional impairment, due to the patients conflict with her mother, the patients problems in school, her difficulties with empathy and remorse in relationships with others, and her recent stabilization of behavior in the inpatient setting. In terms of comorbidity, the records support a score of 3. The patient has significant co-morbidity, due to her multiple psychiatric issues as well as her HIV-positive status. With regards to the level of stress of the recovery environment, the records support a score of 3. The patients recovery environment is moderately stressful due to the flooding of her familys house and recent relocation, as well as her withdrawal from school and switch to homeschooling. In terms of the level of support of the recovery environment, the records support a score of 3, which corresponds with limited support in the environment, due to the patients family feeling overwhelmed with caring for her. With regards to resiliency and treatment history, the records support a score of 3, which reflects moderate resiliency. In terms of acceptance and engagement of the patient, the records support a score of 3. The patients score reflects that the patient is incompletely engaged, due to the patients reported lack of empathy and remorse. Thus, the patient has a composite score of 22. Using the CALOCUS level of care determination decision tree, the recommended level of care is Level 5: Medically Monitored Residential Services due to the patients serious risk of harm as well as environmental stressors. Furthermore, the patient is scored at Level 5C: Long-Term Medically Monitored Residential Programs, due to her having both chronic and severe deficits in interpersonal relationships as well as the ability to engage in socially constructive activities and the ability to maintain minimal responsibilities. 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. Accordingly, residential treatment center (RTC) placement is medically necessary to treat the patients medical condition.Regarding the question of whether continued acute inpatient treatment is appropriate until a Level 5C residential treatment center (RTC) placement is secured for the patient, CALOCUS guidelines state that in assigning levels of care, there will be some systems that do not have comprehensive services for all populations at every level of the continuum. When this is the case, the level of care recommended by CALOCUS may not be available and a choice will need to be made as to whether more intensive services or less intensive services should be provided. In most cases, the higher level of care should be selected, unless there is a clear and compelling rationale to do otherwise. Final Result: The reviewer determined that the requested services 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.