Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The enrollees parent has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) services. The records provided for review indicate that the patients primary issues are depression and anxiety. She has been treated with outpatient therapy and on several occasions indicated that her anxiety had decreased due to her engagement in therapeutic services. She did demonstrate some oppositional behaviors at home and at the RTC. However, the treatment progress notes did not report any severe behavioral issues or violent outbursts. She has not reported any active suicidal or homicidal ideation and has not been engaging in self-harm. She has been eating and sleeping well. The patient has not displayed aggression towards peers or staff since admission to the RTC. The American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) provides a reliable framework for determining the appropriate level of care for adolescents needing mental health treatment. Using CALOCUS, providers score patients on a scale of 1-5 using a six-pronged Dimensional Rating System. The six dimensions include: (1) risk of harm; (2) functional status; (3) medical, addictive and psychiatric comorbidity; (4) recovery environment (a. stressors and b. supports); (5) treatment and recovery history; and (6) engagement. The composite score is then used to determine the level of care needed. Per CALOCUS, RTC level of care requires a composite score of at least 23. Regarding the six CALOCUS dimensions, the patient has some risk of harm with a history of cutting, and she has not expressed any active suicidal or homicidal ideation or intent (score = 2). Regarding functional status, she has had some issues with level of function due to mental illness and relational issues, but overall showed appropriate daily functioning while in treatment (score = 2). There are no comorbidities noted (score = 1). The patient has a positive recovery environment and a stable housing situation. Although the patient was noted to have interpersonal conflict with family members, the progress notes document that family sessions have been productive and not adversarial (score = 2). The patients parents are involved and supportive (score = 2). Further, the patient has demonstrated some response, but has continued anxiety and depression (score = 3), actively participates in therapy for a majority of the time, but has also been uncooperative on occasion (score = 3), and has parents who work actively and constructively with clinicians (score = 2). For a CALOCUS composite score of 17, the recommended level of care is high-intensity outpatient therapy. Therefore, the RTC services were not and are not medically necessary for 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 subspecialty 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.