Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has reimbursement and prospective authorization and coverage for any of the acute psychiatric inpatient treatment level of care. Findings:  The physician reviewer found that 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 2. The patient has a history of aggression. The patients aggression seemed to have improved since being at Resnick Neuropsychiatric Hospital. There are no reports of self-harm or past suicide attempts, although there are concerns for suicidal ideation. The patient is still at some risk given chronic poor judgment and poor impulse control.In terms of functional status, the records support a score of 4. The patient has demonstrated serious functional impairment. The patient was having difficulties with toileting. Performing activities of daily living appeared inadequate and required 1:1 support and attention. The patient was placed in a behavioral program at Resnick Neuropsychiatric Hospital and demonstrated progress, but still required ongoing staff encouragement/support for adequate oral intake. With regard to comorbidity, the records support a score of 5. The patient has a neurodevelopmental disorder with concerns for chromosomal abnormality. He has a history of growth delay, reading delay/challenges, severe rigidity, sensitive to sensory input, and picky eating. In terms of level of stress of the recovery environment, the records support a score of 3. The patients parents appear well-meaning; however, there are concerns for the limited skills that the caretakers have in order to manage the patients needs.With regard to level of support of the recovery environment, the records support a score of 3 due to the patients parents limited ability to respond appropriately to the patients needs/problems, with difficulties carrying through with the structure the patient has required for recovery.In terms of resiliency and treatment history, the records support a score of 4. The patient had poor response to past treatment and limited improvement to previous hospitalization. The patient has demonstrated evidence of innate vulnerability under stress and difficulties resuming progress toward expected developmental level. This is in part due to his neurodevelopmental disorder compromising overall understanding of his eating disorder.With regard to treatment acceptance and engagement, the records support a score of 3 as the patient appears to have incomplete engagement. The patient has still required a behavioral plan at the hospital and has continued to resist accepting age-appropriate responsibility for intake and needs considerable staff support.Thus, the patient has a total score of 24. The records support a 4 in terms of functional status. In this case, the recommended level of care was medically monitored residence-based services. The patient has had challenges with developing insight into the dangerous nature of his own restrictive eating. The patient has required significant behavioral and medical support around attempts to reverse his perseverations around restrictive eating as well as managing his poor activities of daily life skills. Although the patient has demonstrated improvement, he still requires this level of care for support. In this patients case, acute psychiatric inpatient treatment level of care provided and forward was and is in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the services at issue were and are clinically appropriate in terms of type, frequency, extent, site, and duration. The services at issue were not and are 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, acute psychiatric inpatient treatment level of care provided and forward was and is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the services at issue were and are 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 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.