Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) services. 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 binging and purging prior to admission to the RTC, multiple past suicide attempts, and reported suicidal ideation while at the RTC. In terms of functional status, the records support a score of 3. The documentation noted moderate functional impairment due to his withdrawing from his parents, social anxiety, and inability to focus on his academic work.With regard to comorbidity, the records support a score of 1. The patient did not have comorbidities. 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 disruptions from the pandemic, conflict with parents, and academic pressures. With regard to level of support of the recovery environment, the records support a score of 2 due to his parents participation in treatment. 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 due to continued struggles with anxiety, depression, and disordered eating despite therapeutic interventions and a prior psychiatric hospitalization. With regard to treatment acceptance and engagement, the records support a score of 2. The patient was motivated and actively participated in treatment. Thus, the patient has a total score of 17. 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 CALOBUC 5b extended stay criteria. This is consistent with the care the patient received and is receiving at the RTC. This 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 services were and are 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.