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

The patient has requested reimbursement 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 met the criteria for RTC services. For dimension 1, the patient was at serious risk of harm (score 4) due his assaultive behavior and elopement from the previous RTC, as well as anger outbursts and defiance towards staff at the second RTC. There was indication or report of significant impulsivity and/or physical or sexual aggression, with poor judgment and insight, and that were significantly endangering to others. For dimension 2, the patient demonstrated serious functional impairment (score 4) given his serious deterioration of interpersonal interactions with consistent conflict or otherwise disrupted interactions with others, which included impulsive or abusive behaviors. The patient was discharged from the previous RTC after assaulting a peer and running away. He also struggled with interactions with peers and staff at the second RTC. For dimension 3, the patient has no comorbidities (score 1). No evidence of medical illness, substance abuse, developmental disability, or psychiatric disturbances apart from the presenting condition. For dimension 4A, the patients recovery environment was moderately stressful (score 3) considering his multiple moves between home and various treatment settings, which supports disruption of family and social milieu. For dimension 4B, the patients recovery environment was supportive (score 2) due to his mothers active participation in treatment. The patients family were willing and able to participate in treatment if requested to do so and had capacity to effect needed changes. For dimension 5, the patient exhibited poor resiliency and response to treatment (score 4). The records document that previous treatment has not achieved complete remission of symptoms or optimal control of symptoms even with intensive and repeated exposure to treatment. The patient has persistent symptoms despite an extensive treatment history at various levels of care, including RTC. For dimension 6, the patient was incompletely engaged in treatment (score 3) given his tendency to blame others rather than accept responsibility for his own actions and their consequences. The patient minimized and rationalized distressing behaviors and consequences. This gives the patient a composite score of 21, which is consistent with Level 4 medically monitored community-based services. Per CALOCUS, the patients score of 4 for risk of harm supports an indication for Level 5 medically monitored residence-based services. Furthermore, the patient qualified for Level 5C long-term medically monitored residence-based services since his symptoms were persistent despite extensive and intensive treatment exposure. These facilities will provide intensive treatment as described for all Level 5 programs and the length of stay varies from two months to one year. In this case, the patients longstanding behavior problems, failure to make progress at lower levels of care, and aggressive and impulsive outbursts required longer-term RTC. Therefore, the RTC services were medically necessary for treatment of this patient.