Residential Treatment Facility denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The patient’s parent has requested reimbursement for all or any of the residential treatment facility (RTC) 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. Using CALOCUS-CASII, providers score patients on a scale of 1-5 using a six-pronged Dimensional Rating System.

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for residential treatment facility level of care services. 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.

Where the denial was upheld

The parent of an enrollee has requested reimbursement for residential treatment level of care services. Findings: The physician reviewer found that the documentation provided do not support the medically necessity of the services at issue in this clinical setting. The progress notes indicate that the patient showed openness to discussion of her issues. She was cooperative in treatment. During the period in dispute the patient did not show any dangerous behaviors towards herself or others. She was not displaying any significant or severe behavioral problems. It is evident that she needs more treatment to further improve her social functioning, depression, school participation, and family relationships. However, the records indicate that she did not need the restrictiveness of a residential psychiatric treatment facility.

The patient is a 14-year-old female with an extensive history of mental illness who has received mental health treatment since the age of eight years. She has had suicidal thoughts in the past and was admitted to an inpatient psychiatric unit on two previous occasions. It does not appear from the record there has been an actual suicide attempt. The patient was admitted to the residential treatment facility in June 2006 for mood swings and depression. She was evaluated by a psychiatrist and diagnosed with major depressive disorder. The patient was started on the antidepressant medication doxepin, with titration of her dosage during her stay. She showed some improvement in her symptoms and behavior and as of July 2006, according to the notes of her mental health providers, she was not having suicidal/homicidal thoughts and was not actively psychotic.

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 Facility, then check the rights and deadlines that apply to your plan.