Appeal type: Medical Necessity
Decision: Overturned 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. 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 mental health RTC services. For dimension 1, the patient has been at significant risk of harm (score 3) given her history of self-harm via cutting and suicidal gestures via overdose on melatonin gummies and attempted strangulation in front of her parent. The patient reported ongoing suicidal ideation prior to RTC admission.  The patient has no active or suicidal ideation, but extreme distress and a history of suicidal behavior. For dimension 2, the patient has demonstrated serious functional impairment (score 4) due to her school avoidance, social anxiety, panic attacks, mood instability, and depressive symptoms. The patient has engaged in self-harm and suicide attempts, and reports having emotional outbursts and conflicts with her family. 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 3) given her social anxiety, ADHD, hypothyroidism, anxiety and depression. The provider also noted concern for gender dysphoria. Psychiatric signs and symptoms are present that persist in the absence of stress, are moderately debilitating, and adversely affect the presenting condition. For dimension 4A, the patients recovery environment is highly stressful (score 4). The provider noted that the patients brother has behavioral and emotional instability, which has included threatening the patient with a knife. The patients parents have been described as invalidating. The patient has been exposed to endangering circumstances within her home and family. For dimension 4B, the patients recovery environment provides limited support (score 3) considering her brothers history of threatening behaviors and conflicts with the patient, and invalidation from her parents. Family displays limited ability to partial ability to make necessary changes during treatment. For dimension 5, the patient has exhibited poor resiliency and response to treatment (score 4) due to her history of limited response to outpatient therapy and continued poor functioning while at home and in the community. The patient has been unable to attend school or maintain her safety within her home. 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) given her history of poor compliance with medications and poor response to outpatient therapy. The patient has ambivalent, avoidant, or distrustful relationships with clinicians and other care providers. These findings give the patient a composite score of 24, which is consistent with medically monitored residence-based services. Moreover, the patients score of 4 on functional status supports treatment at the RTC level of care. Although the records suggest that the patient had improved behaviors, she continued to require RTC level of care to address chronic family dynamic concerns and longstanding maladaptive patterns of suicidal ideation and self-harm. The RTC level of care is appropriate for the multimodal intervention that this patient has required. Therefore, the mental health RTC services provided were and are medically necessary for treatment of this patient.Final Result: The reviewer determined that the services at issue were and 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.