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

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement 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. Applying CALOCUS, this patient met the criteria for psychiatric RTC services. The patient was at serious risk of harm (score 4) due to suicidal ideation, recent suicide attempts, impulsivity, mood lability, and impaired judgment. The patient demonstrated moderate functional impairment (score 3) given her troubled relationship with her parents, academic difficulties, and stabilization achieved in the RTC setting. The patient has no reported significant comorbidities (score 1) based on a lack of substance abuse, medical illness, or developmental disability. The patient was noted to have a mildly stressful recovery environment (score 2) considering her academic difficulties and conflict with her parents over her gender identity. The patients recovery environment provided limited support (score 3) as her parents were struggling to keep the patient safe at home, and had difficulty accepting the patients gender dysphoria. The patient has exhibited poor response to treatment (score 4) with a lack of improvement in symptoms after two hospitalizations and two courses of PHP treatment. The patient was incompletely engaged in treatment (score 3) due to her inconsistent participation in RTC program activities. This gives the patient a composite score of 20, which is consistent with medically monitored community based services. Due to the patients score of 4 on risk of harm, the patient qualified for Level Five, medically monitored residence based services. Furthermore, the patient met the criteria for Level 5B intermediate stay medically monitored residence based services, due to a lack of response at lower levels of care, recent gains made in the context of a highly structured setting, impulsivity, history of suicidality, and need for placement in an alternative residential school program. Per CALOCUS, treatment at this level of care usually does not exceed 60 days. This patients 45-day admission to the RTC level of care was within the recommended timeframe for this level of care. All told, the psychiatric RTC services 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.