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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested reimbursement for psychiatric residential treatment center (RTC) services from 9/05/20 through 10/03/20.At issue in this case is whether the psychiatric RTC services from 9/05/20 through 10/03/20 were medically necessary to treat the patients medical condition.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. Using CALOCUS, providers score patients on a scale of 1-5 using a six-pronged Dimensional Rating System. The six dimensions include: (1) risk of harm; (2) functional status; (3) medical, addictive and psychiatric comorbidity; (4) recovery environment (a. stressors and b. supports); (5) treatment and recovery history; and (6) engagement. The composite score is then used to determine the level of care needed. Applying the CALOCUS framework, the patient meets the criteria for psychiatric residential treatment services.With regard to risk of harm, the records support a score of 3. The patient had a significant risk of harm, due to binge or excessive use of alcohol and other drugs resulting in potentially harmful behaviors, as well as a history of self-harm. In terms of functional status, the records support a score of 3. The documentation noted moderate functional impairment, due to conflict with parents, but also an ability to maintain a high level of school performance.With regard to comorbidity, the records support a score of 3. The patient had significant comorbidity, due to a combination of substance use, attention deficit hyperactivity disorder (ADHD), and anxiety and mood symptoms.In terms of level of stress of the recovery environment, the records support a score of 2. The patient had a mildly stressful environment, due to academic pressures and the disruptions caused by the pandemic, as well as the recent breakup with his girlfriend.With regard to level of support of the recovery environment, the records support a score of 2 due to his parents participation in treatment and treatment planning.In terms of resiliency and treatment history, the records support a score of 3. The patient had moderate or equivocal resiliency and/or response to treatment. The patient had not responded to outpatient therapy and medication management, and his functioning had deteriorated somewhat while at home during the pandemic. He had not tried higher levels of outpatient care.With regard to treatment acceptance and engagement, the records support a score of 3 as the patient appeared incompletely engaged, due to his desire to continue drinking after discharge, and his reluctance to accept the home contract.Thus, the patient has a total score of 19. Based on the CALOCUS algorithm, the recommended level of care during the period under review in this case is Level Three: High-Intensity Community-Based Services. The records indicate that the patient was admitted to residential care without any prior experience in treatment other than low-intensity outpatient therapy and medication management. Although his symptoms and behavior were concerning, they do not meet the criteria for serious risk of harm or serious functional impairment typically needed to justify residential care. There is no indication that it would have been unsafe for the patient to participate in a highly structured outpatient program instead of residential treatment. Therefore, psychiatric residential treatment center (RTC) services from 9/05/20 through 10/03/20 were not medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the services at issue were 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 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.