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

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement for residential treatment center (RTC) services. The American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists CALOCUS guideline 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 met the criteria for RTC services. For dimension 1, the patient was at serious risk of harm (score 4) due to repeated expression of suicidal ideation at the RTC and prior hospitalization due to suicidal ideation with plan. While in RTC, the patient continued to struggle with repeated non-suicidal self-harm. The records document current suicidal ideation with either clear, expressed intentions and past history of carrying out such behavior. The patient expressed ambivalence about carrying out the safety plan and/or her familys ability to carry out the safety plan was compromised.For dimension 2, the patient demonstrated moderate functional impairment (score 3) given her social isolation, recent academic issues, difficulty getting out of bed, and struggles with daily hygiene tasks. This supports that the patients self-care and hygiene deteriorated below usual or expected standards on a frequent basis. For dimension 3, the patient has no reported comorbidities (score 1). The records do not document any developmental or medical concerns or significant substance use. There is no evidence of medical illness, substance, abuse, developmental disability, or psychiatric disturbances apart from the presenting condition. For dimension 4A, the patients recovery environment was moderately stressful (score 3) given the disruptions caused by the pandemic and her parents marital issues. The records document disruption in family and social milieu. For dimension 4B, the patients recovery environment was supportive (score 2) due to her parents active participation in treatment and treatment planning. The patients parents were willing and able to participate in treatment if requested to do so and had capacity to effect needed changes. For dimension 5, the patient has exhibited poor resiliency and response to treatment (score 4) considering the patients continued struggles with suicidality, depression, and anxiety, such that the patient required hospitalization while in RTC. Previous treatment has not achieved complete remission of symptoms or optimal control of symptoms, even with intensive and repeated exposure to treatment. For dimension 6, the patient was constructive in treatment (score 2) due to her engagement with providers and her treatment milieu. The patient was able to develop a trusting, positive relationship with clinicians and other care providers. These findings give the patient a composite score of 19, which is consistent with high intensity community-based services. The patients score on risk of harm supports Level 5, medically monitored residence-based services. Furthermore, the patient qualified for Level 5B intermediate stay medically monitored residence-based services due to recent suicidal ideation as well as subsequent gains made in the structured setting of the RTC. Per CALOCUS, the length of stay at Level 5B usually does not exceed 60 days. The RTC services were within this timeframe. Moreover, the RTC services were in accordance with the generally accepted standards of mental health and substance use disorder care, clinically appropriate in terms of type, frequency, extent, site, and duration, and not primarily for the convenience of the patient or provider. Therefore, the RTC services applying the CALOCUS guidelines were medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were 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.