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

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for dual diagnosis residential treatment center (RTC) services in a secure facility. 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 in a secure facility. For dimension 1, the patient has been at serious risk of harm (score 4) given his significant compromise in function and risk of harm to self and others prior to admission. The patient has a history of aggression toward others, self-harm, and suicidality. The patient has required multiple prior psychiatric hospitalizations and emergency room visits. The records also document ongoing active substance use, school failure, and high family conflict with poor coping skills. Moreover, the patient eloped from the RTC without permission while at RTC. Indication or report of significant impulsivity and physical aggression, with poor judgment and insight, that are significantly endangering to self and others.For dimension 2, the patient has demonstrated serious functional impairment (score 4) due to his inability to function at school or home, with concerns of running away, substance abuse, and aggression towards self and others with poor social skills. Serious deterioration of interpersonal interactions with consistent conflict or otherwise disrupted interactions with others, which may include impulsive or abusive behaviors. For dimension 3, the patient has significant comorbidities (score 4) considering his diagnoses of autism and PTSD. The patient also has multiple substance use disorders that are in remission due to being in a controlled environment. The patient is noted to have a history of psychosis related to substance 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). The records document a very stressful environment involving severe conflicts with parents and peers. There is a serious disruption of family and social milieu due to severe conflict. For dimension 4B, the patients recovery environment provides limited support (score 3) given the ongoing severe conflicts with his parents and not perceiving his parents as supportive. Family has limited ability to respond appropriately to the patients developmental needs and problems. For dimension 5, the patient has exhibited poor resiliency and response to treatment (score 4) considering his poor recovery history. Despite seeing a psychiatrist since he was five-years-old, and a history of therapy and hospitalizations, the patient has continued with high-risk behaviors and severe mood and safety concerns. 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) as he has expressed ongoing cravings and he continues to have peer relational conflicts while at RTC. Ambivalent, avoidant, and distrustful relationship with clinicians and other care providers. These findings give the patient a composite score of 26, which is consistent with Level 5 medically monitored residence-based services. This level of care is also supported given the patients scores of 4 on risk of harm, functional status and comorbidity. The patient has consistently demonstrated severe compromise in functioning when not in a structured and contained setting. His insight is low, and progress has been slow. The patient has significant relationship issues impairing recovery and severe substance use disorders. Per CALOCUS, he therefore meets Level 5C extended stay criteria. Moreover, the patient has reportedly eloped from RTC in the past. Therefore, dual diagnosis RTC services in a secure facility are medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested services 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.