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 her history of self-harm behaviors, recurrent substance use, and her ambivalence about maintaining sobriety. The records also note that the patient has a history of violence including aggression toward others, refusal to attend school and criminal activity. She is described as highly impulsive with difficulty managing her anger. There is indication or report of significant impulsivity and physical aggression with poor judgment and insight, and that are significantly endangering to self and others. For dimension 2, the patient has demonstrated moderate functional impairment (score 3). The records document that the patient has made gains in her functioning while in treatment. In addition, the patient has severe deficits in interpersonal relationships with her parents. Recent gains in functioning have been achieved while participating in treatment in a structured, protected, and enriched service. For dimension 3, the patient has major comorbidities (score 4) given her history of significant substance use and remains pre-contemplative with regards to her cannabis use. Uncontrolled substance use is present that poses a serious threat to health if unabated and impedes recovery from the presenting condition. For dimension 4A, the patients recovery environment is highly stressful (score 4) considering her family relationships that are highly conflictual. The provider noted significant conflict in the patients relationships with her mother and biological father. The patient is struggling with the suicide of an aunt and she has experienced legal issues related to her substance use. The patient is ambivalent about remaining sober from cannabis use and she has not been attending virtual school. This supports serious disruption of family milieu due to death and severe conflict. For dimension 4B, the patients recovery environment has provided limited support (score 3) as her home environment includes high conflict. The patients parents are currently involved in a custody dispute, which has been associated with a high level of conflict. The patients family has limited ability to respond appropriately to the patients developmental needs or problems or is ambivalent toward meeting these needs or addressing these problems. For dimension 5, the patient has exhibited poor resiliency and response to treatment (score 4). Previous year-long outpatient treatment did not ameliorate symptoms, which have reportedly escalated. 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 has been incompletely engaged in treatment (score 3). The providers noted that the patient has been able to engage in treatment during the residential stay, but there is concern that the patients engagement is not genuine given her intention to return to her social life and social media. Ambivalent, avoidant or distrustful relationship with clinicians and other care providers. This gives the patient a composite score of 25, which is consistent with medically monitored residence-based services. Moreover, the patients scores of 4 on risk of harm and comorbidities, the patient qualifies for Level 5 medically monitored residence-based services. Given these findings, the mental health 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.