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 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 meets the criteria for RTC services. For dimension 1, the patient has been at serious risk of harm (score 4) due to indication or report of significant impulsivity and physical aggression, with poor judgment and insight, and that are significantly endangering to self or others. Moreover, the patient has a clear and persistent inability, given developmental stage, to maintain physical safety or use environment for safety. This is demonstrated by the patients recent repeated episodes of self-harm, intrusive suicidal thoughts, and her dysregulated mood. For dimension 2, the patient has demonstrated moderate functional impairment (score 3), given her conflict with parents, episodes of purging, disordered eating, and gains made in the structured setting of the RTC. Recent gains and stabilization in functioning have been achieved while participating in treatment in a structured, protected, and enriched service. For dimension 3, the patient has minor comorbidities (score 2) based on declining use of alcohol during the pandemic, and denial of other substance use. Occasional, self-limited episodes of substance use are present that show no pattern of escalation, with no indication of adverse effect on functioning or the presenting condition. For dimension 4A, the patients recovery environment is mildly stressful (score 2). The records document that the patient has conflict with her parents, and she has experienced disruptions caused by the pandemic. Also, there are expectations for performance at home or school that create discomfort as demonstrated by the patients statements about her parents high expectations and her fear of making mistakes. For dimension 4B, the patients recovery environment has been supportive (score 2) since her parents have actively participated in her treatment. Family caretakers are willing and able to participate in treatment if requested to do so and have capacity to effect needed changes. For dimension 5, the patient has exhibited poor resiliency and response to treatment (score 4). In this case, the patient reportedly relapsed with purging and self-harm after RTC and PHP treatment, and continued to struggle with depression, anxiety, and panic attacks. Previous treatment has not achieved complete remission of symptoms or optimal control of symptoms even with intensive and/or repeated exposure to treatment. In addition, attempts to maintain whatever gains that were attained in intensive treatment have limited success, even for limited time periods or in structured setting.  For dimension 6, the patient has been constructive in treatment (score 2). The provider reported that the patient has been an active participation in treatment. The patient has been able to develop a trusting, positive relationship with clinicians and other care providers. These findings give the patient a composite score of 19, consistent with high intensity community-based services. Per CALOCUS, the patients score of 4 on risk of harm supports medically monitored residence-based services, such as RTC. Furthermore, the patient qualifies for Level 5B intermediate stay medically monitored residence-based programs. The patient has made progress toward her goals in the setting of the RTC and struggled while in less intensive care. Per CALOCUS, treatment at level 5B typically lasts up to 60 days. Therefore, the RTC services 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.