Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement for all or any 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 active suicidal ideation. In terms of functional status, the records support a score of 4. The documentation noted serious functional impairment due to the patients difficulty with boundaries and inability to participate in school for one and a half months prior to admission to the RTC. With regard to comorbidity, the records support a score of 4. The patient had digestive issues possibly related to Ehlers-Danlos syndrome and an eating disorder with binging, purging, and restricting behaviors. 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 severe disruption to her environment because of the COVID-19 pandemic.  With regard to level of support of the recovery environment, the records support a score of 3 as the patients family had limited ability to respond appropriately to the patients needs and community resources were unable to meet the patients needs, particularly during the pandemic. In terms of resiliency and treatment history, the records support a score of 4. The records noted poor resilience and/or response to treatment as the patient was vulnerable to stress and did not have coping skills. Despite multiple treatment attempts at several levels of care, the patient continued to fail to achieve remission of symptoms and to maintain gains outside of a highly structured environment. With regard to treatment acceptance an engagement, the records support a score of 3. While at the RTC, the patient continued to act out and was noted to report being overstimulated as a way to withdraw and avoid participating in treatment.  Thus, the patient has a total score of 25. The records support a 4 in terms of risk of harm, functional status, and comorbidity. In this case, the recommended level of care was medically monitored residence-based services. In this patients case, RTC level of care was in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the services at issue were clinically appropriate in terms of type, frequency, extent, site, and duration. The services at issue were 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 medically necessary for the treatment of this patient.Final Result: The reviewer determined that the services at issue were 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 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.