Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for psychiatric residential treatment center (RTC) services. The American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) provides a reliable framework for determining the appropriate level of care for adolescents needing 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) treatment and recovery history; and (6) engagement. The composite score is then used to determine the level of care needed. For dimension 1, the patient has been at serious risk of harm (score 4) due to indication or report of significant impulsivity with poor judgment and insight, and that are significantly endangering to self or others. The patients parents reported concern about their safety and the safety of their younger sibling due to the patients behavior at home. His parents also expressed concern about the patients risk of overdose. The patients outpatient providers noted voiced concerns about the patients safety and recommended residential treatment for this reason. For dimension 2, the patient has demonstrated moderate functional impairment (score 3) with recent gains in functioning achieved while participating in treatment in a structured, protected, and enriched service as evidenced by his improved behavior while at the RTC. Prior to admission, his parents reported to the patients providers that they were walking on eggshells around him due to his volatility, and that their situation was not sustainable. For dimension 3, the patient has significant comorbidity (score 3) considering his recent substance use that has significant impact on the presenting condition has been arrested due to use of a highly structured or protected setting. Per parent and provider report, the patient was using substances regularly at home, but stopped after admission to the RTC. For dimension 4A, the patients recovery environment is mildly stressful (score 2) considering the disruptions caused by the Covid-19 pandemic, and expectations for performance at home and school that create discomfort. The patient stated that he lacks the coping skills needed for coping with life. The records support a significant transition requiring adjustment. For dimension 4B, the patients recovery environment is supportive (score 2) due to parents active participation in treatment. The patients family are willing and able to participate in treatment if requested to do so and have capacity to effect needed changes. For dimension 5, the patient has exhibited poor resiliency and response to treatment (score 4). The records document that previous treatment has not achieved complete remission of symptoms or optimal control of symptoms even with intensive and repeated exposure to treatment, as demonstrated by his worsening depressive symptoms and continued substance use despite extended outpatient services. For dimension 6, the patient has been constructive in treatment (score 2) given his general cooperation with residential treatment and his providers. The providers report that the patient passively cooperates in treatment planning and treatment. These findings give the patient a composite score of 20, which is consistent with medically monitored community-based services. As noted in CALOCUS, due to the patients score of 4 on risk of harm, the recommended level of care is Level 5 medically monitored residence-based services. Furthermore, the patient qualifies for Level 5B intermediate stay medically monitored residence-based services. The provider documented that recent gains and/or stabilization in functioning have been achieved while participating in treatment in a highly structured, protected, and/or enriched service. Moreover, the patients substance use has been temporarily arrested during his stay in residential treatment. Per CALOCUS, the length of stay at Level 5B usually does not exceed 60 days. Given these findings, RTC services for 60 days is appropriate. Therefore, the psychiatric RTC services were and are medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were and are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in psychiatry with subspecialty 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.