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

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested re-admittance to Residential Treatment Center (RTC) services.The Child and Adolescent Level of Care Utilization System (CALOCUS) provides a reliable framework for determining the clinically appropriate level of care for a child or adolescent in 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 (Astressors, and B-supports); (5) resiliency and treatment history; and (6) treatment acceptance and engagement. The composite score is then used to determine the level of care needed.For dimension 1- Risk of Harm. This dimension assesses potential for harm to self or others. During his recent outpatient visit, the patient reported no suicidal or homicidal ideation, and he denied substance use. The patients parent reports, however, that the patient has a history of suicidal ideation and threats. The patient therefore has a past history of fleeting suicidal or homicidal thoughts with no current ideation, plan, or intention. [Score 2  some risk of harm]For dimension 2  Functional Status. This dimension assesses the degree to which a person is able to fulfill social responsibilities, interacts with others, and maintains physical functioning and capacity for self-care. The patient reported that he had learned coping skills in residential treatment, that he had remained sober since his discharge, and that he was committed to sobriety. Although the patient described behaviors such as stealing and lying in the present tense during his outpatient assessment, records indicate that these behaviors occurred when the patient was using substances, and the patient reported being sober before he first received residential treatment center services. While this date does not exactly correspond to the dates of sobriety the patient reported upon his admission to residential treatment, he consistently reported being sober for 4 to 5 weeks before starting residential treatment. [Score 2  mild functional impairment]For dimension 3  Comorbidity. This dimension assesses potential complications in the course of treatment due to acuity or disability related to co-occurring medical illness, substance use disorder, or psychiatric disorder. The patient reported that he had been using substances heavily but quit using prior to his admission to the residential treatment center, and that he then maintained sobriety during and after residential treatment. The patient therefore had recent substance use that had a significant impact on his presenting condition and which had been arrested due to use of a highly structured or protected setting or through other external means. [Score 3  significant co-morbidity]For Recovery Environment dimension 4A- Stress. This dimension assesses the stressors in the patients environment, social circumstances, and interpersonal relationships. The patient experienced disruptions due to the experience of residential treatment as well as the restrictions of the pandemic. [Score 2  mildly stressful environment]For Recovery Environment dimension 4B- Support. This dimension assesses the presence of family and social support to augment the patients recovery environment. The patients parents had active involvement in the patients treatment, with some movement between households. The patients family was therefore willing and able to participate in his treatment if requested to do so and have a capacity to effect needed changes. [Score 2  supportive environment]For dimension 5- Treatment and Recovery History. This dimension assesses how past experiences with treatment and recovery might indicate how the patient might respond in the future. The patient reports successfully maintaining sobriety after leaving treatment. In addition, his mood appears to have improved, as he denies anxiety symptoms and symptoms of depression. The patients previous experience in treatment or with formal supports has therefore been successful in controlling his symptoms. [Score 2  significant resiliency and/or response to treatment]For dimension 6  Engagement. This dimension assesses a persons understanding of their illness and treatment, and their ability and willingness to engage in the treatment process. The patient has voiced motivation for continued sobriety and he is seeking support through treatment. The patient is actively participating in treatment planning and is cooperating with treatment. [Score 1 - optimal]These findings give the patient a composite CALOCUS score of 14, which is consistent with Level 2: Low Intensity Community-Based Services. Clinical services for outpatient care consist primarily of individual, group, and family therapies with active family participation in treatment planning and implementation. Treatment intensity ranges from one hour every four weeks to up to two hours per week. Accordingly, the requested re-admittance to Residential Treatment Center (RTC) is not medically necessary for the patients medical condition.Final Result: The reviewer determined that the requested services are not medically necessary for the patient's 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.