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, and reimbursement and prospective authorization and coverage for mental health 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.With regard to risk of harm, the records support a score of 4. The patient had a serious risk of harm, due to significant impulsivity, with poor judgment and insight, as demonstrated by jumping out of a second floor window with the intention of self-harm, and elopement from home. In terms of functional status, the records support a score of 3. The documentation noted moderate functional impairment due to conflicts with the patients mother and struggles with completing daily activities, followed by gains made in the structured setting of the RTC. With regard to comorbidity, the records support a score of 1. The patient had no comorbidity, due to the absence of substance abuse, medical problems, or developmental disorders.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 conflict with her mother, recent losses of a friend and her grandfather, and disruptions caused by the COVID-19 pandemic. At the time of readmission, the records documented her mothers upcoming surgery for breast cancer. With regard to level of support of the recovery environment, the records support a score of 2 due to her mothers participation in treatment and treatment planning.In terms of resiliency and treatment history, the records support a score of 3. The patient had moderate or equivocal resiliency and/or response to treatment. Previous experience in treatment at low level of intensity, such as eight weeks of intensive outpatient program (IOP) participation, had not been successful. With regard to treatment acceptance and engagement, the records support a score of 2. The patient demonstrated active participation in treatment at the RTC. Thus, the patient has a total score of 18. In this case, the recommended level of care was medically monitored residence-based services due to the risk of harm score of 4. This is consistent with the level of care that the patient received at the RTC. Moreover, going forward, the patient qualifies for Level 5B level of care, an intermediate stay medically monitored residential program, based on the following criteria, Child or adolescent experiences some suicidal or homicidal ideation with some ambivalence, or is highly distressed with some history of harm to self or others. Impulsivity may be present and the risk of engaging in destructive behaviors is significant in an unstructured environment...recent gains and/or stabilization in functioning have been achieved while participating in treatment in a highly structured, protected, and/or enriched service. Per CALOCUS, the typical length of stay at Level 5B is up to 60 days. In this case, the patient was at the RTC for 31 days. The patient had made progress in the structured setting of RTC, but upon being prematurely discharged due to COVID-19 exposure, was readmitted. Although PHP had been recommended upon discharge, the patient had instead quarantined at a hotel with a family friend, and then stayed with her grandmother and then with her mother, while dealing with the news of her mothers breast cancer diagnosis. Upon readmission, the provider noted the patient continued to warrant residential care. Given the patients premature discharge from RTC, lack of interim care, and current psychosocial stressors, the services at issue were and are medically indicated. Therefore, mental health RTC services were and are medically necessary for the treatment of this patient.Final Result: The reviewer determined that the services at issue were and are 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 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.