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

The parent of an enrollee has requested reimbursement for residential treatment center 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 (a. stressors 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. The patient had serious risk of harm, due to signs of consistent deficits in her ability to care for herself, as evidenced by patient's continued struggles to adhere to her treatment plan recommendations with regard to food intake and exercise/movement guidelines. The patient's aggressive behavior toward family members also placed her and her family at risk. [Score 4  serious]For dimension 2  Function. 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 had serious functional impairment, due to serious deterioration of interpersonal interactions with consistent conflict or otherwise disrupted interactions with others. The patient was in conflict with her parents about her treatment plan, and had been aggressive at home. In addition, she was not attending school regularly due to being overwhelmed with ruminations about her body image and food. [Score 4  serious]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 had major co-morbidity, as medical conditions were present that would adversely affect, or be affected by, the presenting condition. This was evidenced by the patient's orthostatic hypotension early in her stay at the residential treatment center. [Score 4- major co-morbidity]For Recovery Environment dimension 4A- Stress. This dimension assesses the stressors in the patients environment, social circumstances, and interpersonal relationships. The patients recovery environment was mildly stressful, due to the patient's conflict with parents regarding her eating, as well as the disruptions to her social and educational activities caused by her need for intensive treatment. [Score 2 -mild] For Recovery Environment dimension 4B- Support. This dimension assesses the presence of family and social support to augment the patients recovery environment. The patient had a supportive environment, due to her parents' active participation in treatment. [Score 2- supportive]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 had poor resiliency and/or response to treatment. The patient was unable to maintain the gains she had made previously in residential treatment, and she continued to struggle with disordered eating while participating in outpatient treatment. [Score 4- poor response]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 had constructive engagement, due to her active participation in treatment at the residential treatment center, and her compliance with the treatment plan in that setting. [Score 2- constructive engagement]These findings give the patient a composite CALOCUS score of 22. Due to the patients serious risk of harm and serious functional impairment, however, the patients recommended level of care is Level 5: Medically Monitored Residence-Based Services. Accordingly, the residential treatment center services at issue were medically necessary to treat the patients medical condition.