Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement for residential treatment center (RTC)  level of care services. Findings:  The physician reviewer found that he 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 3. The patient had significant risk of harm due to a history of suicidal ideation, self-injury, and attempted suicide, along with a history of significant substance use, including using hand sanitizer to achieve intoxication. The patient continued to endorse suicidal ideation up to two weeks prior to discharge from the RTC. In terms of functional status, the records support a score of 3. The documentation noted significant functional impairment due to impulsive and risky behaviors along with significant conflict with her parents prior to RTC admission. The patients gains in function while at the RTC were relatively recent. With regard to comorbidity, the records support a score of 4. The patient had serious comorbidity, due to a history of significant substance use. The patient had a history of bingeing and purging, which could lead to metabolic abnormalities and cardiac arrythmias, and of psoriasis and psoriatic arthritis. 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 conflictual relationships with her parents, who were divorced, and her older brother, who she reported had Aspergers and sometimes scared her with his outbursts. With regard to level of support of the recovery environment, the records support a score of 3 due to the patients mothers difficulty in validating the patient and being over-protective of the patient. In terms of resiliency and treatment history, the records support a score of 4. The patients symptoms continued despite previous treatments including outpatient therapy, inpatient psychiatric hospitalizations, and partial hospitalization programs (PHP).With regard to treatment acceptance and engagement, the records support a score of 3. The patients mother participated in family therapy but struggled with validating the patient. Thus, the patient has a total score of 24. The records support a 4 in terms of comorbidity. In this case, the recommended level of care was medically monitored residence-based services. This was consistent with the level of care that the patient received at the RTC. 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 level of care 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 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.