Appeal type: Medical Necessity
Decision: Upheld

StNature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement and prospective authorization and coverage 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. With regard to risk of harm, the records support a score of 3. The patient has a significant risk of harm, due to impulsivity as evidenced by his recent running away from a treatment center. In terms of functional status, the records support a score of 3. The documentation noted moderate functional impairment due to conflict with his family and girlfriend. However, the patient demonstrated recent gains in the protected setting of the RTC. With regard to comorbidity, the records support a score of 3. The patient had significant comorbidity, due to the presence of substance abuse and mental health symptoms. 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 a history of combative behavior with his father. With regard to level of support of the recovery environment, the records support a score of 2 due to the patients mothers involvement in his treatment. In terms of resiliency and treatment history, the records support a score of 3. The patient has moderate resiliency and/or response to treatment due to a lack of improvement with outpatient treatment, followed by stabilization while at the RTC. With regard to treatment acceptance and engagement, the records support a score of 3. The patient demonstrated incomplete engagement, showing some motivation while in treatment along with a tendency to manipulate and to disrespect others.Thus, the patient has a total score of 20. In this case, the recommended level of care is medically monitored community-based services. Therefore, RTC services were not medically necessary for the treatment of this patient. Additionally, RTC services were not and are not medically necessary as defined in Health and Safety code section 1374(a)(3)(A). Specifically, RTC services were not and are not in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, RTC services were not and are not clinically appropriate in terms of type, frequency, extent, site, and duration.Final Result: The reviewer determined that the services at issue were not and are not medically necessary for treatment of the patients medical condition. Additionally, RTC services were not and are not medically necessary as defined in Health and Safety code section 1374(a)(3)(A). Therefore, the Health Plans denial should be upheld.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.