Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement for inpatient psychiatric hospitalization treatment at Rhode Island Hospital. Findings:  The physician reviewer found that (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 3. The patient had some risk of harm, due to chronic, passive suicidal ideation, and intermittent self-injurious behaviors in the form of repeated head-banging and unspecified self-harm. The patient displayed an inability to care for self and/or maintain physical safety in developmentally appropriate ways, and the records noted  periods of extreme distress.In terms of functional status, the records support a score of 4. The documentation noted serious functional impairment due to serious disturbances in physical function and consistent failure to achieve self-care/hygiene at levels appropriate to age and/or developmental level. The patient was using a rolling walker to ambulate, at times falling on his knees, and required monitoring while taking showers due to physical safety concerns. With regard to comorbidity, the records support a score of 3. The patient had significant comorbidity, due to the presence of medical issues, including asthma, postural orthostatic tachycardia syndrome, vestibular migraines, and chronic pain. The patient had difficulty ambulating and required the use of a walker. The records noted weight loss during hospitalization requiring the monitoring of oral intake. 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 a difficult relationship with his father and self-isolation. The patient had stressors including chronic pain and a functional neurologic disorder.With regard to level of support of the recovery environment, the records support a score of 2 due to his parents efforts to arrange treatment for patient and their participation in treatment. In terms of resiliency and treatment history, the records support a score of 4. The patient had poor resiliency and/or response to treatment as he made some progress while hospitalized, but also regressed in physical symptoms, showing heightened anxiety, sensitivity, easily being overwhelmed by minor stressors, and struggles to utilize coping skills. With regard to treatment acceptance and engagement, the records support a score of 2. The patient was active and engaged in his treatment.Thus, the patient has a total score of 21. The records support a 4 in terms of functional status. In this case, the recommended level of care is medically monitored, residence-based services. Therefore, inpatient psychiatric hospitalization treatment at Rhode Island Hospital was not medically necessary for the treatment of this patient.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.