Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement for mental health residential treatment center (RTC) services provided at Newport Academy.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 the presence of substance use, putting herself in unsafe situations, and running away from home multiple times for several days at a time. In terms of functional status, the records support a score of 3. The documentation noted moderate functional impairment due to difficulties with academic work and conflict with her mother. With regard to comorbidity, the records support a score of 3. The patient had significant comorbidity, due to the presence of substance abuse, major depression, and anxiety. In terms of level of stress of the recovery environment, the records support a score of 3. The patient had a moderately stressful environment due to learning about the recent death of her father during her stay in the RTC. With regard to level of support of the recovery environment, the records support a score of 2 due to the patients mother participating in treatment and treatment planning. 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 continued relapses and persistent mood and anxiety symptoms despite multiple recent attempts at higher levels of care, including short-term residential treatment stays within the past year. With regard to treatment acceptance and engagement, the records support a score of 2. The patient actively participated in treatment. Thus, the patient has a total score of 21. The records support a 4 in terms of risk of harm. In this case, the recommended level of care was medically monitored residence-based services. This is 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, mental health RTC services provided at Newport Academy 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.