Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) services at Newport Academy Morada. 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 a history of engaging in illegal activities such as vandalism, trespassing, and substance use. The patient endorsed recurrent passive suicidal ideation without plan or intent, a recent history of self-harm, recurrent substance use and recent relapse.In terms of functional status, the records support a score of 3. The documentation noted moderate functional impairment due a decline in grades due to substance use. The records noted that the patient required continued redirection by staff to start and focus on schoolwork, suggesting that the patients mental health and substance use issues resulted in moderate functional impairment. With regard to comorbidity, the records support a score of 3. The patient had significant comorbidity, due to the presence of depression, anxiety, eating disorder, and substance use disorder. 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 an older brother with a history of substance abuse and reported frustration and stress between family members.With regard to level of support of the recovery environment, the records support a score of 2 due to his parents involvement in the patients treatment and the patient describing a positive relationship with his parents and sibling. 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 the patients symptomatology has persisted despite multiple treatment attempts at various levels of care.With regard to treatment acceptance and engagement, the records support a score of 3. The patient appeared to recognize the need for change, express a desire and willingness to change, and was engaged in treatment, however the patient was also noted as distracted during groups with minimal participation. Thus, the patient has a total score of 21. In this case, the recommended level of care is medically monitored community-based services. This is inconsistent with the level of care that the patient was and is receiving at the RTC. In this patients case, RTC level of care was not and is not in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the services at issue were not and are not clinically appropriate in terms of type, frequency, extent, site, and duration. The services at issue were and are 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 at Newport Academy Morada were not and are not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the services at issue were not and are 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.