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

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement and prospective authorization and coverage for inpatient (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. Applying the CALOCUS framework, this patient meets the criteria for inpatient psychiatric level of care services. For dimension 1, the patient has been at serious risk of harm (score 4) due to significant suicidal ideation with a plan to starve herself occurring over the month prior to hospitalization. The records document that the patient has a healing left inner forearm laceration that has been treated with bacitracin and bandaging. The patient has lost 10 kg since March 2021. Evaluation in the emergency department revealed that the patient was orthostatic. The patient was noted to continue to have ongoing suicidal ideation, irritability, and dysphoria. The patient refused intake once transfer to RTC was mentioned, and she only started improved intake once placement of a nasogastric tube feeding was discussed. The patient has continued to require significant support to meet basic self-care needs including eating and drinking, with ongoing ambivalence about safety, with ongoing active suicidal thoughts. Current suicidal ideation with either clear, expressed intentions and past history of carrying out such behavior. The patient has expressed ambivalence about carrying out the safety plan. For dimension 2, the patient has demonstrated serious functional impairment (score 4) given her serious compromise in functional status as well as ongoing suicidal ideation, anxiety, and OCD symptoms. The patient has been unable to maintain adequate self-care in order to meet basic food and fluid intake requirements without significant external structure and directives by hospital staff. Consistent failure to achieve self-care/hygiene at levels appropriate to age and developmental level. For dimension 3, the patient has major comorbidities (score 4) considering her diagnoses of severe major depressive disorder, without psychotic features, OCD, anxiety, and suicidal ideation. The patients suicidal ideation with intention to starve herself has placed her at significant risk for harm and has resulted in dangerous medical conditions including dehydration and hypotension, with worsening of the patients condition in the absence of hospital level of care to support. Medical conditions are present that will adversely affect, or be affected by, the presenting condition. For dimension 4A, the patients recovery environment has been highly stressful (score 4). The records document an antagonistic and conflictual relationship with her mother that is passive aggressive. The records document the presence of high familial stress. This supports disruption of family and social milieu. For dimension 4B, the patients recovery environment has been minimally supportive (score 4) given the patients history of multiple mental health interventions with limited progress, with concerns of ongoing tense and difficult familial relationships. The patients parent has demonstrated limited ability to manage and support the patients needs. Family or primary caretaker is seriously limited in ability to provide for the patients developmental, material, and emotional needs. For dimension 5, the patient has exhibited negligible resiliency and response to treatment (score 5). The provider documented that the patients past response to treatment has been minimal even at high levels of care for long periods of time. The patient has a history of multiple inpatient stays given concerns about continued suicidal ideation and suicide attempts. The patient has been treated with multiple medication trials including fluoxetine, Zoloft, Luvox, and lithium, with limited results. Past response to treatment has been quite minimal, even when treated at high levels of care for extended periods of time. For dimension 6, the patient has been non-collaborative in treatment (score 4) due to her passive aggressive behaviors, adversarial presentation, and ambivalent dynamics with providers and her mother. The hospital staff just started to develop some therapeutic alliance in late May 2021. Actively hostile relationship with clinicians and other care providers despite competent efforts to engage with the patient. These findings give the patient a composite score of 29, which is consistent with medically managed residence-based services. This patient has a long history of mental health difficulties with multiple suicide attempts and inpatient psychiatric care as well as history of RTC level of care for several months. The patient continues to require Level 6 medically managed residence-based services in order to manage the patients suicidal ideation with intention to die via restrictive intake. The patient has stable vitals and a normal BMI, but this is due to the high level of support and structure the providers have been providing at the inpatient level of care. All told, the inpatient psychiatric level of care services provided 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. psychiatric level of care services. Findings:  The physician reviewer found that