Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested reimbursement for residential treatment center (RTC) services. 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. In this case, CALOCUS scores are determined as follows:With regard to risk of harm, the records support a score of 4. The patient repeatedly expressed suicidal ideation at the RTC, and was unable to contract for safety and was taken to the hospital for a psychiatric evaluation. In terms of functional status, the records support a score of 3. The patient made progress with regard to meal compliance and other treatment goals at the RTC. With regard to comorbidity, the records support a score of 2. The patient had minor 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 the disruptions caused by the pandemic and extended stays in residential and inpatient treatment.With regard to level of support of the recovery environment, the records support a score of 2 due to their parents active participation 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 struggle with disordered eating, suicidality, depression and anxiety despite extended inpatient and residential treatment. With regard to treatment acceptance and engagement, the records support a score of 3 as the patient appeared incompletely engaged, due to their impulsive running away from facility.Thus, the patient has a total score of 20. Per the CALOCUS algorithm, the recommended level of care during the period under review in this case is Level Five: Medically Monitored Residence-Based Services, due to serious risk of harm. Furthermore, the patient qualified for Level 5B: Intermediate Stay Medically Monitored Residential Programs, due to suicidal ideation, lack of response to previous treatment, and recent gains made in the residential setting. Continued treatment at this level of care was prudent, given the patients instability. Total length of treatment at RTC should be determined at the discretion of the treatment team. 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. Thus, residential treatment center (RTC) services were medically necessary to treat the patients medical condition.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.