Residential Treatment Center Care denials: what the review data shows

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for residential treatment center (RTC) care services for a total of 72 remaining days of a 90-day program.At issue in this case is whether the RTC care services for a total of 72 remaining days of a 90-day program are medically necessary to treat the patient’s medical condition as defined in Health and Safety code section 1374.72(a)(3)(A) set forth below.

Findings: The physician reviewer found that The patient’s parent has requested reimbursement and prospective authorization and coverage for any or all of the residential treatment center (RTC) level of care services. The American Academy of Child and Adolescent Psychiatry (AACAP) and American Association for Community Psychiatry (AACP) have unified the Child and Adolescent Level of Care Utilization System (CALOCUS) and the Child and Adolescent Service Intensity Instrument (CASII) into a single instrument, the Child and Adolescent Level of Care/Service Intensity Utilization System (CALOCUS-CASII). This instrument is a standardized tool used to determine the intensity of services needed for children and adolescents, 6-18 years of age, presenting with psychiatric, substance use, medical and/or developmental concerns.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The patient’s parent has requested reimbursement for residential treatment center (RTC) level of care. 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. Findings: The physician reviewer found that With regard to risk of harm, the records support a score of 3. The patient had significant risk of harm, due to a history of self-harm with scissors, passive suicidal ideation, laxative abuse, purging, and struggles to maintain adequate nutrition.In terms of functional status, the records support a score of 3.

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for all or any of the residential treatment center (RTC) level of care provided. The American Association of Community Psychiatrists Level of Care Utilization System (LOCUS) provides a reliable framework for determining the appropriate level of care for adults needing mental health treatment. Using LOCUS, 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) medical, addictive and psychiatric comorbidity; (4) recovery environment (a. stressors and b. supports); (5) treatment and recovery history; and (6) engagement. The composite score is then used to determine the level of care needed. With regard to risk of harm, the records support a score of 3.

These are outcomes from California’s external review program — an independent physician panel that binds the insurer. Every state has an equivalent process, and internal appeals succeed even more often. Cite the outcome record for Residential Treatment Center Carewhen you appeal: reviewers routinely find that denials like yours didn’t hold up.