Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement for all or any 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. With regard to risk of harm, the records support a score of 4. The patient had a serious risk of harm due to decompensating mental health and a history of manic symptoms, impulsive behavior, substance use, and an overdose attempt resulting in hospitalization. In terms of functional status, the records support a score of 4. The documentation noted serious functional impairment due to impulsive behavior, physical aggression, substance use, and a decline in academic performance. With regard to comorbidity, the records support a score of 4. The patient had major comorbidity due to the presence of substance abuse, psychiatric symptoms, suspected irritable bowel syndrome/Crohns disease, and apraxia.  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 conflicts with her parents and siblings over her behavior. With regard to level of support of the recovery environment, the records support a score of 2 due to her parents efforts to be present and supportive. In terms of resiliency and treatment history, the records support a score of 4. The patient had poor response to treatment and recovery management due to ongoing erratic and aggressive behavior and substance use despite a history of prior treatment, including intensive outpatient program (IOP), inpatient treatment, and three admissions to the emergency room in the past year.  With regard to treatment acceptance and engagement, the records support a score of 2. The patient demonstrated insight and was engaged in treatment. Thus, the patient has a total score of 22. The records support a 4 in terms of risk of harm, functional status, and comorbidity. In this case, the recommended level of care is medically monitored residence-based services. With the elevated risk of harm, functional status, and comorbidity noted, the patient met CALOCUS 5b extended stay criteria. 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, RTC 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.