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

The patient has requested reimbursement for 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 the CALOCUS framework, this patient met the criteria for RTC services. For dimension 1, the patient was at serious risk of harm (score 4) since he required hospitalization due to suicidal ideation with a plan to overdose just a few weeks prior to his admission to the RTC. This was the patients second hospitalization for suicidality in one year. Although he remained safe in the structured environment of the RTC, the patient would have been at elevated risk of another episode of suicidality had he returned home. The records support current suicidal or homicidal ideation with either clear, expressed intentions and past history of carrying out such behavior. The patient expressed ambivalence about carrying out the safety plan. For dimension 2, the patient demonstrated moderate functional impairment (score 3) due to difficulty with interpersonal interactions with peers and parents. The patient demonstrated conflicted, withdrawn, or otherwise troubled in relationships with peers, adults, and/or family, but without episodes of physical aggression. For dimension 3, the patient has significant comorbidities (score 3) given the recent previous hospitalization after overdosing on edible cannabis. There was evidence of recent substance use that had significant impact on the presenting condition was arrested due to use of a highly structured or protected setting or through other external means. For dimension 4A, the patients recovery environment was moderately stressful (score 3) given the presence of parental conflict and his mothers mental health and substance use struggles. The records support disruption of family milieu. For dimension 4B, the patients recovery environment was supportive (score 2) due to his parents active participation in treatment. The patients primary caretakers were willing and able to participate in treatment of requested to do so and had capacity to effect needed changes. For dimension 5, the patient showed poor resiliency and response to treatment (score 4) considering the lack of improvement in depressive symptoms after multiple psychiatric hospitalizations, and treatment at various levels of care as an outpatient. 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 his active participation in treatment as noted by the providers. 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 21. Based on the patients risk of harm score of 4, RTC level of care was indicated. Furthermore, the patient qualified for level 5C long-term medically monitored residence-based services since the patients symptoms were persistent despite extensive and intensive treatment exposure. Per CALOCUS, treatment at Level 5C, the length of stay will vary from two months to a year. The patient participated in the wilderness program for less than three months, which was within the recommended guidelines. For these reasons, the 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.