Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement and prospective authorization and coverage for any or all of the residential treatment center (RTC) level of care.Findings:  The physician reviewer found that 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 two recent suicide attempts and continued suicidal ideation without intent or plan. In terms of functional status, the records support a score of 4. The documentation noted serious functional impairment due to serious deterioration of interpersonal interactions with consistent conflict. The patient has a history of aggression with peers and siblings, family conflict despite five years of weekly family therapy, and boundary violations with peers. With regard to comorbidity, the records support a score of 3. The patient had significant comorbidity, due to the presence of a recent mild autism spectrum diagnosis, which may affect his peer interactions and social skills. 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 family conflict and disruptions to schooling caused by the pandemic. With regard to level of support of the recovery environment, the records support a score of 2 due to the family's efforts to participate in treatment and accept the patient's gender identity exploration. In terms of resiliency and treatment history, the records support a score of 4. The patient had poor resiliency and/or response to treatment due to a serious suicide attempt via overdose despite participating in years of family therapy, partial hospitalization program (PHP) and intensive outpatient program (IOP). With regard to treatment acceptance and engagement, the records support a score of 2. The patient demonstrated high motivation and active participation in treatment. Thus, the patient has a total score of 22. The records support a 4 in terms of risk of harm and functional status. In this case, the recommended level of care is medically monitored residence-based services. With the functional impairment and 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 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.