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

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for residential treatment center (RTC) for two to six months. 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 RTC services for two to six months. For dimension 1, the patient is at serious risk of harm (score 4) given his history of self-harm behaviors and current suicidal ideation. At the time of patients most recent hospital admission, he endorsed constant thoughts of suicide with a plan to cut his wrists and neck and drown himself. The patient attempted to carry out this plan and was intercepted. He has a history of self-harm behaviors and prior suicide attempt. Current suicidal ideation with clear, expressed intentions and a past history of carrying out such behavior. For dimension 2, the patient has demonstrated moderate functional impairment (score 3) due to his failing grades despite having an individualized education program. He has also engaged in impulsive behaviors such as eloping from his home and going to a river with the intention of committing suicide. School behavior has deteriorated to the point of the patient has faced some school disciplinary action and is at risk for placement in an alternative school program. For dimension 3, the patient has major comorbidities (score 4) considering his history of difficulty falling and staying asleep. The patients depression and sleep problems are bidirectional since each can contribute to the onset and exacerbation of the other. Furthermore, the provider described the patient as having several developmental disabilities including autism, a learning disability, and intellectual disability. Medical conditions are present that will adversely affect, or be adversely affected by, the presenting condition. For dimension 4A, the patients recovery environment is moderately stressful (score 3). The provider noted that the patient has experienced difficulty keeping friends and when he feels rejected, he engages in self-harm. He is failing in school and his parent reported worsening symptoms secondary to COVID-19 social isolation. The patient also noted to have a conflictual relationship with his older brother. These factors support a disruption of family and social milieu. For dimension 4B, the patients recovery environment is supportive (score 2) based on his parents willingness to participate in the patients treatment. However, the patient has a conflictual relationship with his brother. Primary caretakers are willing and able to participate in treatment if requested to do so and have the capacity to effect needed changes. For dimension 5, the patient has exhibited poor resiliency and response to treatment (score 4) since he has been hospitalized psychiatrically on at least four occasions. He has also participated in a partial hospitalization program (PHP) and outpatient therapy. 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). The provider charted that although the patient has attended and participated in groups and activities, the patient can be manipulative and attention-seeking. Ambivalent, avoidant, or distrustful relationship with clinicians and other care providers. These findings give the patient a composite score of 23, which is consistent with medically monitored residence-based services. Per CALOCUS, the patients scores of 4 on risk of harm and comorbidities also support Level 5 medically monitored residence-based services. With regard to the length of stay in residential treatment, the patient meets the requirements for RTC services for two to six months. The patient has been hospitalized on an inpatient psychiatric unit for at least 35 days and has engaged in 10 days of a PHP since late 2020. However, his mental health symptoms have not been well managed, and he has been unable to maintain his safety for any significant length of time outside of a highly structured treatment setting. For these reasons, the requested RTC services for two to six months are medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested services 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.