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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Residential Treatment Center level of care. Findings:  The physician reviewer found that 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. 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 (Astressors, and B-supports); (5) resiliency and treatment history; and (6) treatment acceptance and engagement. The composite score is then used to determine the level of care needed. In this case, the patients CALOCUS scores would have been as follows:For dimension 1  Risk of Harm. This dimension assesses potential for harm to self or others, or having harm inflicted upon them. The patient evidenced no suicidal ideation or intention, but she was experiencing significant distress and had a history of self-inflicted pain and suicidal ideation. [Score 3  Significant Risk of Harm]For dimension 2  Functional Status. This dimension assesses the degree to which a person is able to fulfill responsibilities for a given age level. The records note that the patient suffered some deterioration in self-care and significant weight loss related to a past traumatic experience. [Score 3  Moderate Functional Impairment]For dimension 3  Comorbidity. This dimension assesses the co-existence of disorders across four domains (psychiatric, substance use, medical or developmental) that may complicate the course of treatment. The patient was healthy and athletic. Despite some weight loss, there was no significant threat to her health. She had some past episodes of substance use, but these were quite limited and did not have a significant impact on her emotional health on the date of assessment. [Score 2  Minor Co-Morbidity]For dimension 4A  Recovery Environment  Stress. This dimension assesses the stressors in the environment, social circumstances, and interpersonal relationships. The patients level of stress diminished to some degree during the first seven days of treatment, but there was still significant worry regarding her social circumstances and the sequelae of a breakup with her boyfriend. [Score 3  Moderately Stressful Environment]For dimension 4B  Recovery Environment  Support. This dimension assesses the presence of family and social support to augment the recovery environment. The patient described her parents as supportive and they actively participated in the treatment program. There is some suggestion in the progress notes that their attention and involvement may have been somewhat inconsistent. [Score 2  Supportive Environment]For dimension 5  Resiliency and Treatment History. This dimension assesses success or failure to make use of treatment and natural support that fosters resilience. The patients treatment by outpatient therapy and medication prior to admission was not successful in reducing her symptoms. [Score 3  Moderate or Equivocal Resiliency and/or Response to Treatment]For dimension 6  Treatment Acceptance and Engagement. This dimension assesses a persons understanding of their illness and treatment, and their ability and willingness to engage in the treatment process. The patient demonstrated an ability to develop a positive relationship to clinicians and accepted responsibility for her behavioral change. [Score 2  Constructive]These findings give the patient a composite CALOCUS score of 18, which is consistent with Level Three: High Intensity Community Based Services. This level of care is consistent with intensive outpatient services. Accordingly, the Residential Treatment Center services at issue were not medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the services at issue were not medically necessary to treat the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in 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.