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

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 patients medical condition as defined in Health and Safety code section 1374.72(a)(3)(A) set forth below. Medically necessary treatment of a mental health or substance use disorder means a service or product addressing the specific needs of that patient, for the purpose of preventing, diagnosing, or treating an illness, injury, condition, or its symptoms, including minimizing the progression of that illness, injury, condition, or its symptoms, in a manner that is all of the following: (i) in accordance with the generally accepted standards of mental health and substance use disorder care; (ii) clinically appropriate in terms of type, frequency, extent, site, and duration; (iii) not 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.The American Association of Community Psychiatrists 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) 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. Applying the CALOCUS framework, the patient meets the criteria for psychiatric residential treatment services. With regard to risk of harm, the records support a score of 4. The patient does not have a history of suicidal ideation or behaviors. He struggles with temper tantrums and aggression, becomes angry with little provocation, escalates rapidly, and is verbally and physically aggressive to others. The patient has been in multiple fights with peers, suggesting poor impulse control and a clear inability to maintain physical safety appropriate to his developmental age. There is also indication that patient has been sexually aggressive. In terms of functional status, the records support a score of 4. The patient does not regularly attend virtual schooling, completes less than 70% of work assigned, and is performing in the bottom 10% of his class. The patient is also noted to have poor frustration tolerance, is prone to aggressive outbursts, and has difficulty making/keeping friends. He has been disciplined numerous times at school for inappropriate and aggressive behaviors and has had multiple school suspensions. The records provided do not indicate whether receipt of special education services has enabled the patient to be more successful in school. He lacks respect for authority and has explosive anger outbursts with minimal trigger. This suggests serious functional impairment.With regard to comorbidity, the records support a score of 3. The patient has gastroesophageal reflux disease and difficulty sleeping. Sleep issues can adversely impact behavior and judgment, suggesting significant comorbidity. In terms of level of stress of the recovery environment, the records support a score of 3. The patients parents are divorced. The patient has significant conflict with his parents because of his anger issues. He is bullied at school because of his anger issues. The patients recovery environment appears moderately stressful, as the patient has not been successful at school, and his anger and aggression have caused difficulties in his relationships. With regard to level of support of the recovery environment, the records support a score of 2 due to his sisters support and positive relationship with his parents. In terms of resiliency and treatment history, the records support a score of 4. From the records available for review, it appears that the patient has been engaged in outpatient psychiatry visits every 2-3 months for the last two years. He has been tried on several medications, and the records suggest that these medications have been helpful. However, the patient demonstrates frequent evidence of innate vulnerability under stress, as evidenced by his frequent anger and aggressive outbursts to minor upsets. This suggests poor resiliency and/or response to treatment.With regard to treatment acceptance and engagement, the records support a score of 3. The patient appears to be participating in outpatient psychiatry visits, and he appears to have been compliant with psychoeducational testing. However, in residential treatment, he has been inconsistently engaged in treatment and is noted to present as immature, lacking in insight and socially isolative. The records also indicate that patient minimizes and makes excuses for his behaviors. He has difficulty with perspective taking. This suggests incomplete engagement.These findings give the patient a composite score of 23, which is consistent with Level 5 Medically Monitored Residence Based Services. Per CALOCUS, this patients scores of 4 for risk of harm and functional status also support treatment at with Level 5 Medically Monitored Residence Based Services level of care. For these reasons, RTC care services for a total of 72 remaining days of 90-day program are medically necessary for the treatment of patients medical condition. RTC care services for a total of 72 remaining days of a 90-day program are in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, RTC care services for a total of 72 remaining days of a 90-day program are clinically appropriate in terms of type, frequency, extent, site, and duration. The requested RTC care services for a total of 72 remaining days of a 90-day program are not 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.Final Result: The reviewer determined that the requested services 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 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.