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

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement for residential treatment center (RTC) services. Findings:  The physician reviewer found that (CALOCUS) provides a reliable framework for determining the appropriate level of care for adults 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) medical, addictive, 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, the patient did not meet the criteria for RTC services.For dimension 1, the patient was at significant risk of harm (score 3) due to a history of suicidal ideation and self-harm behaviors in the form of superficial cutting and scratching. The provider noted that the patient did not engage in self-harm during treatment. The patient continued to have suicidal ideation during the RTC admission, but she denied having a plan. The provider described the patient as distressed at times after disclosing a history of sexual abuse. No active suicidal or homicidal ideation, but extreme distress and a history of suicidal behavior. For dimension 2, the patient demonstrated moderate functional impairment (score 3) since the patient described herself as very emotional after disclosing a history of abuse. During the admission, the patient continued to struggle with anxiety, guilt, and shame. The patient participated in treatment and was noted to benefit from the program. Recent gains and stabilization in functioning were achieved while participating in treatment in a structured, protected, and enriched service. For dimension 3, the patient has significant comorbidities (score 3) considering her struggles with obesity, which plays a role in her poor self-esteem and contributes to her depression. The patient is also described as a stress eater, which suggests that she uses food to reduce distress and regulate her emotions. The patient was being treated with oral contraceptives for treatment of menorrhagia, which can also adversely affect her mood. Medical conditions are present that may adversely affect, or be adversely affected by, the presenting condition. For dimension 4A, the patients recovery environment was moderately stressful (score 3). She has a history of molestation as a child and about one year prior to admission. The patient reported that she has been bullied because of her weight. The patient described a strained relationship with her father and no contact with an older sibling. The patients grandfather died two years ago, and this was described as a significant loss. This supports disruption of family milieu and interpersonal loss that has significant impact on the patient and family. For dimension 4B, the patients recovery environment was supportive (score 2). The patient has stated that she has a few close friends who are supportive. She has a friendship relationship with her mother and a good relationship with her sister. 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 significant resiliency and response to treatment (score 2). The provider noted that prior to admission to RTC, the patients previous treatment only included outpatient psychotherapy. The patient reportedly benefitted from RTC. Recovery has been managed for short periods of time with limited support or structure. For dimension 6, the patient was constructive in treatment (score 2) due to her utilization of individual and family therapy. Per the discharge summary, the patient engaged in and benefitted from treatment. Able to develop a trusting, positive relationship with clinicians and other care providers. These findings give the patient a composite score of 18, which is consistent with Level 3 high intensity community-based services. Moreover, the RTC services were not in accordance with the generally accepted standards of mental health and substance use disorder care or clinically appropriate in terms of type, frequency, extent, site, and duration. For these reasons, the psychiatric RTC services were not medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. 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.