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

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement and prospective authorization and coverage for RTC level of care. 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 4. The patient had a serious risk of harm, due to a history of two suicide attempts requiring hospitalization. The patient continued to report self-harm and endorsed symptoms of anxiety and depression. He appeared to be easily triggered by his peers.In terms of functional status, the records support a score of 3. The documentation noted moderate functional impairment due to self-harm and ongoing suicidal ideation. The patient was failing some of his classes. He reported symptoms of anxiety, and the records noted that he was withdrawn, and appeared triggered by his peers. With regard to comorbidity, the records support a score of 3. The patient had significant comorbidity, due to symptoms of anxiety and depression, along with gender dysphoria, PTSD, and restrictive eating. The records noted low self-esteem and persistent worries about others.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 limited support in the home environment, with siblings with mental health issues. With regard to level of support of the recovery environment, the records support a score of 2 due to his parents being willing and able to participate in treatment. In terms of resiliency and treatment history, the records support a score of 5. The patient had negligible resiliency and/or response to treatment due to minimal response to multiple levels of care including psychiatric hospitalization and PHP. With regard to treatment acceptance and engagement, the records support a score of 3. The patient was noted to be minimize or rationalize distressing behaviors and consequences, including a history of intense suicide attempts, and with poor insight and judgement.Thus, the patient has a total score of 23. The records support a 4 in terms of risk of harm. In this case, the recommended level of care is medically monitored residence-based services. With the elevated risk of harm noted, the patient meets CALOCUS 5b, extended stay criteria.  This is consistent with the level of care that the patient was and is receiving at the RTC. In this patients case, RTC level of care was and is in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, 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. Therefore, RTC level of care was and is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the services at issue were and 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.