Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for (1) residential treatment center (RTC) services and (2) RTC services for 6 months. 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 a history of two prior suicide attempts by overdose, a recent hospitalization due to suicidal ideation with plan and intent, and ongoing suicidal ideation. In terms of functional status, the records support a score of 4. The documentation noted serious functional impairment due to serious deterioration of interpersonal interactions with consistent conflict. The patients family reported being unable to control the patients behavior or keep her safely at home, and her most recent hospitalization was prompted by an argument with her mother. With regard to comorbidity, the records support a score of 1. The patient does not have comorbidities.In terms of level of stress of the recovery environment, the records support a score of 2. The patient had a mildly stressful environment due to losing her father to a drug overdose in the summer 2019, and her mental health deteriorated following this loss. With regard to level of support of the recovery environment, the records support a score of 2 due to her mothers involvement and participation in treatment. In terms of resiliency and treatment history, the records support a score of 4. The patient had poor resiliency and/or response to treatment due to persistent suicidal ideation, mood and anxiety symptoms despite prior inpatient hospitalizations, intensive outpatient program and partial hospitalization program treatments. With regard to treatment acceptance and engagement, the records support a score of 3. The patient demonstrates a lack of motivation for treatment. Thus, the patient has a total score of 20. The records support a 4 in terms of risk of harm and functional status. In this case, the recommended level of care is medically monitored residence-based services. With the functional impairment and elevated risk of harm noted, the patient meets CALOCUS 5b extended stay criteria.  This is consistent with the level of care that the patient is receiving at the RTC. In this patients case, RTC level of care is in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the requested services are clinically appropriate in terms of type, frequency, extent, site, and duration. The requested services 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, RTC services up to 60 days are medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested services are partially medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially 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.