Appeal type: Medical Necessity
Decision: Upheld 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. Findings:  The physician reviewer found that (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 does not meet the criteria for RTC services. For dimension 1, the patient has been at some risk of harm (score 2) due to chronic poor impulse control, reactivity, and difficult family dynamics. The patient has a history of vague suicidal ideation but denies current suicidal ideation. The patient does not have a reported history of self-harm or suicide attempt. The patient has experienced physical altercations with his father. Past history of fleeting suicidal thoughts with no current ideation, plan, or intention and no significant distress. For dimension 2, the patient has demonstrated moderate functional impairment (score 3) given his history of challenges in the home setting, getting along with family members, and having reactive behaviors including defiance and verbal reactivity. There is report of physical aggression, a history of sneaking out to meet with his girlfriend, and vandalism. Overall, the patient appears to have variably severe deficits in interpersonal relationships with family, but he has maintained his ability to engage in socially constructive activities such as school, building things, fixing things, and socializing. The patients father is noted to have a history of inflicting corporal punishment. Chronic and variably severe deficits in interpersonal relationships, but with ability to engage in socially constructive activities, and ability to maintain relationships. For dimension 3, the patient has minor comorbidities (score 2) considering his diagnoses including attention-deficit/hyperactivity disorder (ADHD), oppositional defiant disorder (ODD), and parent-child conflict. The patient has no comorbid medical issues or substance use concerns. Minimal developmental delay, disorder or brain dysfunction is present and has no impact on the presenting condition for which the patient has achieved satisfactory adaptation and/or compensation. For dimension 4A, the patients recovery environment has been highly stressful (score 4). The providers noted that the patients parents are divorced. The patients father has an authoritarian parenting style, with evidence of significant parent-child problems. This supports serious disruption of family and social milieu. For dimension 4B, the patients recovery environment has provided limited support (score 3). The provider charted that the patients parents have limited skills to respond to the patients behavioral problems, with limited use of collaborative problem solving approaches. Family has limited ability to respond appropriately to the patients developmental needs and/or problems or is ambivalent toward meeting these needs to addressing these problems. For dimension 5, the patient has exhibited moderate or equivocal resiliency and response to treatment (score 3) since the patient has been treated with counseling but no medication trials. There is no mention of prior intensive outpatient program (IOP) or partial hospitalization program (PHP) participation. The patient also has demonstrated an equivocal capacity to deal with stressors and maintain expected functioning. The patient has demonstrated an inconsistent or equivocal capacity to deal with stressors and maintain normal development. For dimension 6, the patients parents have been incompletely engaged in treatment (score 3) given their inability to engage, collaborate, and problem solve regarding the patients concerns. This supports inability to collaborate in development of treatment plan. These findings give the patient a composite score of 20, which is consistent with Level 4 medically monitored community-based services. The records document a history of untreated ADHD and severe parent-child relational problems with significant defiance, irritability, verbal aggression and periodic physical conflict. The patient would likely benefit from more intensive community treatment, such as IOP or PHP or wraparound services with family therapy. Moreover, the RTC services are not clinically appropriate in terms of type, frequency, and duration. Given these findings, the RTC services were not and are not medically necessary for treatment of the patients mental health or substance use disorder as defined in Health and Safety Code section 1374.72(a)(3)(A).Final Result: The reviewer determined that the services at issue were not and are 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.