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

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement 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 met the criteria for RTC services. For dimension 1, the patient was at significant risk of harm (score 3) due to his inability to perform activities of daily living including not showering, changing clothes, and unwillingness to get haircut. The patient was also noted to have very limited nutritional intake, which qualified him as having periods of inability to care for self. The patient demonstrated periods of inability to care for self and maintain physical safety in developmentally appropriate ways. For dimension 2, the patient has demonstrated serious functional impairment (score 4) given his inability to perform activities of daily living (ADLs), inadequate nutritional intake, limited socialization, and increased irritability with family. The provider also noted that the patient engaged in functionally bizarre behaviors such as wearing several layers of clothes and gloves everywhere. This supports significant withdrawal and avoidance of almost all social interaction, and consistent failure to achieve self-care/hygiene at levels appropriate to age and developmental level. For dimension 3, the patient has significant comorbidities (score 3) considering his diagnoses of pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS), obsessive-compulsive disorder (OCD), avoidant/restrictive food intake disorder, and persistent depressive disorder. Developmental disability is present that may adversely affect the presenting condition, and/or may require significant augmentation or alteration of treatment for the presenting condition or comorbid condition, or adversely affects the presenting condition. For dimension 4A, the patients recovery environment was moderately stressful (score 3). The records document that the patients family is supportive, but they have excessively accommodated the patients OCD issues. This supports a disruption in family and social milieu. For dimension 4B, the patients recovery environment provided limited support (score 3) since his parents have attempted to be supportive. However, his parents have been unable to provide the kind of structure and therapeutic environment at home to prevent excessive accommodation for the patient, thus contributing toward worsening of the patients presentation. Family has limited ability to respond appropriately to the patients developmental needs and problems or is ambivalent toward meeting these needs or addressing these problems.For dimension 5, the patient has exhibited poor resiliency and response to treatment (score 4) due to his history of treatment with multiple providers on an outpatient basis, without success in improving the patients symptoms prior to RTC admission. Previous treatment has not achieved complete remission of symptoms or optimal control of symptoms even with repeated exposure to treatment. For dimension 6, the patient has been incompletely engaged in treatment (score 3) since prior to RTC admission, the patient was not showering or performing other ADLs, with severe nutritional limitations. The patient partially responded to RTC level of care. Acknowledges existence of problem but resisted accepting even limited age-appropriate responsibility for development, perpetuation, or consequences of the problem. These findings give the patient a composite score of 23, which is consistent with medically monitored residence-based services. The patient demonstrated severe and debilitating OCD symptoms that limited his social function and ability to care for himself, as well as severely compromise his health status given his limited nutritional intake. He demonstrated significant improvement at the RTC level of care and appeared to require this level of care in order to improve given multiple factors and considerations. All told, the RTC services were medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were 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.