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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) services at Eating Recovery Center of Washington from 6/16/21 forward.At issue in this case is whether the RTC services at Eating Recovery Center of Washington from 6/16/21 forward were and/or are medically necessary to treat the enrollees mental health or substance use disorder medically necessary as defined in Health and Safety code section 1374(a)(3)(A) set forth below. Medically necessary treatment of a mental health or substance use disorder means a service or product addressing the specific needs of that patient, for the purpose of preventing, diagnosing, or treating an illness, injury, condition, or its symptoms, including minimizing the progression of that illness, injury, condition, or its symptoms, in a manner that is all of the following: (i) in accordance with the generally accepted standards of mental health and substance use disorder care; (ii) clinically appropriate in terms of type, frequency, extent, site, and duration; (iii) 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.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. With regard to risk of harm, the records support a score of 4. The patient has a history of self-injurious behaviors in the form of cutting and scratching. Records indicate that patient reports cutting herself multiple times most recently two years ago. She denied a prior history of suicide attempts and denied suicidal ideation on admission. However, the patient reported being unable to eat solid foods due to concerns about texture, and her oral intake was less than 600 calories per day. This places the patient at significant risk of harm given the physical health consequences of severe dietary restriction. In terms of functional status, the records support a score of 4. The patient demonstrated serious functional impairment given her inability to appropriately feed herself in order to maintain health. During her recent stay in residential treatment, she has required a nasogastric tube for feedings, and the most recent records indicate that patient has not been eating by mouth at least 50% of her caloric requirement. This suggests serious functional impairment.With regard to comorbidity, the records support a score of 4. The patient has significant comorbidity considering her diagnosis of malnutrition, dizziness, syncope and near syncopal episodes. The patient suffers from severe abdominal pain which may play a role in her dietary restriction. Eating to restore weight can also lead to potentially lethal refeeding syndrome. The patient also has a history of amenorrhea secondary to her eating disorder and endometriosis. This suggests major comorbidity.In terms of level of stress of the recovery environment, the records support a score of 4. The patients parents are divorced, and her father reportedly has struggled with addiction issues. The patient describes a poor relationship with one of her two sisters. She has also described her relationships with family members as up and down. This suggests a highly stressful environment.With regard to level of support of the recovery environment, the records support a score of 2. The patient describes having a close relationship with her oldest sister and reports that her relationship with her mother has improved since treatment at her last residential treatment facility. The patients mother appears to have been involved in the patients care.In terms of resiliency and treatment history, the records support a score of 4. The patient has shown poor response to treatment and recovery management. She had one previous stay in an eating disorder residential treatment program for over three months from December 2020 to March 2021. Records indicate that she relapsed after discharge. She has also participated in outpatient treatment. This suggests poor resiliency and/or poor response to treatment.With regard to treatment acceptance and engagement, the records support a score of 3 as the patient appears to be somewhat engaged in treatment but struggles to utilize distress tolerance and other coping skills during mealtimes. This suggests incomplete engagement.Thus, the patient has a composite score of 25, which is consistent with Level 5 Medically Monitored Residence Based Services. Per CALOCUS, the patients  scores of 4 for Risk of Harm and Function, and Comorbidity status also support treatment at with Level 5 Medically Monitored Residence Based Services level of care. For these reasons, residential treatment center services at Eating Recovery Center of Washington from 6/16/21 forward were and are medically necessary to treat the patients mental health disorder. The services at issue were and are in accordance with the generally accepted standards of mental health and substance use disorder care. 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.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 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.