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. 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 significant risk of harm (score 3) given his heavy abuse of multiple substances. The patient exhibited severe emotional lability, engaged in property destruction, and threatened harm to others. Indication or report of incidents of acting without thinking, physically aggressive actions that endanger self or others, and breaking laws. For dimension 2, the patient demonstrated serious functional impairment (score 4) with bouts of severe agitation and mood lability with multiple depressive symptoms related to heavy drug use and family dynamic concerns. The patient was noted to be failing school. 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) considering his major depression, anxiety, and concerns for attention-deficit/hyperactivity disorder (ADHD). The patient also has severe alcohol use disorder and cannabis use disorder. Substance abuse is present, with significant adverse effect on functioning and the presenting condition. For dimension 4A, the patients recovery environment was moderately stressful (score 3). The provider noted that the patients family has experienced challenges with healthy communication, which has resulted in severe resentment in the patient towards his parents. This supports disruption of family milieu.  For dimension 4B, the patients recovery environment provided limited support (score 3) since his parents attempted to be supportive but were unable to maintain structure and limits within the home. This facilitated the patients ongoing heavy substance use while at home, an inability to manage his mood, and episodes of behavior dysregulation. 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 shown negligible response to treatment (score 5), due to his lack of response to outpatient services, with a worsening of symptoms. Symptoms are persistent and functional ability shows no significant improvement despite intensive treatment exposure. For dimension 6, the patient was incompletely engaged in treatment (score 3) with expression of resentment and urges to use as well as labile and intimidating behaviors toward others. Unable to accept others definition of the problem and its consequences. These findings give the patient a composite score of 24, which is consistent with medically monitored residence-based services. Moreover, the patients score showing serious functional impairment supported medically monitored residence-based services. For these reasons, 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.