Residential Treatment denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement for residential treatment (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. Using CALOCUS, providers score patients on a scale of 1-5 using a six-pronged dimensional rating system. The six dimensions include: (1) risk of harm; (2) functional status; (3) developmental, medical, substance use and psychiatric comorbidity; (4) recovery environment (A–stressors, and B-supports); (5) resiliency and treatment history; and (6) treatment acceptance and engagement. The composite score is then used to determine the level of care needed.For dimension 1 – Risk of Harm.

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement and authorization and coverage for residential treatment services for three months.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. Using CALOCUS, providers score patients on a scale of 1-5 using a six-pronged dimensional rating system. The six dimensions include: (1) risk of harm; (2) functional status; (3) developmental, medical, substance use and psychiatric comorbidity; (4) recovery environment (A–stressors, and B-supports); (5) resiliency and treatment history; and (6) treatment acceptance and engagement. The composite score is then used to determine the level of care needed.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment for treatment of the enrollee’s behavioral health conditions. Findings: The physician reviewer found that The physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the services at issue. This patient presented to the residential treatment center with a history of opiate use. He expressed motivation for his treatment. During treatment, the patient was noted to be cooperative and calm. Per the records, he showed insight into his illness. The progress notes did not document psychosis, paranoia or mania symptoms during the residential treatment stay. The records did not indicate severe psychiatric symptoms that would require intensive psychiatric care.

The patient is a 24-year-old female with long-standing bulimia nervosa, polysubstance abuse, and major depression, previously treated in a number of eating disorder programs. She was admitted to residential treatment on 1/11/05 due to binging and purging cycles lasting all day within the past two years. This was interspersed with excessive sleeping, drinking alcohol 2-3 nights a week to the point of intoxication, promiscuity and use of methamphetamine as well as cocaine almost daily. Apparently, the patient found the drug use useful in partially helping her stop the binging. She had been unable to hold a job due to lateness, fatigue, and sense of illness due to the vomiting.Review of her chart notes indicates the patient did become variably involved in her residential treatment program, consisting of various group therapies, inclusive of family therapy, and pharmacotherapy.

Compare residential, PHP, IOP, inpatient, and withdrawal-management disputes without mixing TMS into the facility-intensity denominator: behavioral-health level-of-care evidence guide.

These outcomes describe eligible cases completed through California DMHC’s Independent Medical Review program. They do not estimate the chance that an internal appeal, an external review in another jurisdiction, or your individual case will succeed. Use the record to identify evidence patterns involving Residential Treatment, then check the rights and deadlines that apply to your plan.