Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement for inpatient acute care at Alta Bates Summit Medical Center. 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 5. The patient had an extreme risk of harm, due a history of suicide attempts and self-harm. The patient was intermittently refusing meals, stating that she would stop eating but for the threat of nasogastric tube.In terms of functional status, the records support a score of 4. The documentation noted serious functional impairment due to continued struggles with eating, impaired attention, and inability to think logically.With regard to comorbidity, the records support a score of 4. The patient had major comorbidity, due to a 40-pound weight loss. She was medically unstable, requiring nasogastric tube feeding, with vital signs notable for tachycardia, and developed a dystonic reaction to prescription Reglan. In terms of level of stress of the recovery environment, the records support a score of 4. The patient had a highly stressful environment due to family conflict surrounding a move from Switzerland to San Diego. The patients parents appeared involved in treatment but were unable to offer 24-hour supervision. With regard to level of support of the recovery environment, the records support a score of 3 due to her parents support and involvement in treatment, although access to appropriate eating disorder programs was limited due to wait lists and the patients level of severity of eating disorder requiring a nasogastric tube.  In terms of resiliency and treatment history, the records support a score of 5. The patient had negligible response to treatment due to a history of several psychiatric hospitalizations.With regard to treatment acceptance and engagement, the records support a score of 3. The patient appeared to engage in treatment but struggled with cognitive distortions and rigidity. Thus, the patient has a total score of 28. The records support a 5 in terms of risk of harm, and a 4 in terms of functional status and comorbidity. In this case, the recommended level of care was medically managed residence-based services. This was consistent with the level of care that the patient received at inpatient acute care at Alta Bates Summit Medical Center. In this patients case, inpatient acute care 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, inpatient acute care at Alta Bates Summit Medical Center was 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 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.