Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement for inpatient hospitalization. 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 a history of a suicide attempt in the past year by overdosing on pills, self-harm by cutting and dietary restrictions, and substance use. In terms of functional status, the records support a score of 3. The documentation noted moderate functional impairment due to the patients quitting and failing school as a result of depression. The patient had failed to progress and lost weight despite eight months in residential treatment, leading to inpatient hospitalization.With regard to comorbidity, the records support a score of 3. The patient had significant comorbidity, due to a history of substance use and dietary restrictions. The patients vital signs were within normal limits.  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 significant conflict with her father.With regard to level of support of the recovery environment, the records support a score of 3 due to the support of her parents. In terms of resiliency and treatment history, the records support a score of 5. The patient had negligible response to treatment due to continued lack of progress despite an extensive treatment history, including outpatient therapy since age seven, weekly psychotherapy, participation in a four-month wilderness therapy program, and eight months at a residential treatment center (RTC).With regard to treatment acceptance and engagement, the records support a score of 3. The patient was eating meals and agreeable to gaining weight but struggled to respect boundaries. Thus, the patient has a total score of 24. In this case, the recommended level of care is medically monitored residence-based services. In this patients case, inpatient hospitalization was not in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the services at issue were not clinically appropriate in terms of type, frequency, extent, site, and duration. The services at issue were 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, inpatient hospitalization was not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. 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.