Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for any, or all of the residential treatment center (RTC) services.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. Although the patient is age 18, the CALOCUS criteria will be used instead of the adult criteria, due to her developmental status as she was under the care of and living with her parent.With regard to risk of harm, the records support a score of 3. The patient had a significant risk of harm, due to a history of self-harm, suicidal ideation without intent or plan, and difficulty with self-care, as demonstrated by her struggles with hygiene prior to admission, and restricted food intake while at the RTC. In terms of functional status, the records support a score of 4. The documentation noted serious functional impairment due to significant withdrawal, avoidance of almost all social interaction, and consistent failure to achieve self-care/hygiene at levels appropriate to age and/or developmental level. The patient rarely left her home, spent most of her time in her room, was lacking in basic hygiene, and did not participate in school regularly due to her anxiety. With regard to comorbidity, the records support a score of 2. The patient had a minor comorbidity, due to the presence of cannabis use. 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 her father's struggles to care for the patient. With regard to level of support of the recovery environment, the records support a score of 3 as her father, a single parent, struggled to take care of the patient and manage her symptoms and behavior at home. In terms of resiliency and treatment history, the records support a score of 4. The patient had poor response to treatment and recovery management as she did not make progress regarding her anxiety despite outpatient treatment. With regard to treatment acceptance and engagement, the records support a score of 3. The patient demonstrated incomplete engagement, due to her resistance to accepting the need for residential treatment and her inconsistent attendance in RTC activities. Thus, the patient has a total score of 22. The records support a 4 in terms of functional status. In this case, the recommended level of care is medically monitored residence-based services.  With the elevated risk of harm noted, the patient met CALOCUS 5b extended stay criteria. Per CALOCUS, the length of stay at Level 5B usually does not exceed 60 days. At the time of admission, the patient did not meet criteria for Level 5C, long-term medically monitored residential programs for stays of more than 60 days. The records noted that the patient had a successful home visit for three days after almost 60 days of residential treatment, indicating that she was able to function at home for at least a short period of time. Therefore, a portion of the RTC level of care was medically necessary for the treatment of this patient.Final Result: The reviewer determined that a portion of the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially 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.