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 RTC services. For dimension 1, the patient has been at significant risk of harm (score 3) due to a history of a prior suicide attempt, endorsed suicidal ideation, and a history of self-harm behaviors. The patient has continued to self-harm while in the RTC and she reports daily urges to self-harm. The patient has also continued to report passive suicidal ideation, but she reports that she has hope for her life and goals to become a physician. The records document significant current suicidal ideation with some intent and plan, with an ability for the patient to contract for safety and carry out a safety plan. The patient expresses some reason not to carry out such behavior. For dimension 2, the patient has demonstrated moderate functional impairment (score 3) given her serious functional impairment at the time of admission to RTC, but she has demonstrated improvement in attending to her ADLs and her sleep has improved. However, the patient continues to be easily overwhelmed, becomes excessively emotional, and struggles to utilize coping skills, resorting to self-harm. She is also noted to be isolative and withdrawn from her peers. The patient is noted to shut down when discussing difficult family dynamics. The patient has shown recent gains and stabilization in functioning while participating in treatment in a structured, protected, and enriched service. For dimension 3, the patient has significant comorbidities (score 3) considering her daily routine of nicotine use, which has likely exacerbated her anxiety. The patient also has several medical problems including insomnia, stomach pain, and possible endometriosis. The patients depression and anxiety can exacerbate insomnia, and vice versa. Moreover, the patients gastrointestinal distress can be exacerbated by anxiety. Medical conditions are present that may adversely affect, or be adversely affected by, the presenting condition. For dimension 4A, the patients recovery environment is highly stressful (score 4) due to recent allegations of abuse in the home that has required police intervention. The patients sister reportedly also has an eating disorder and recently returned home following inpatient treatment. The provider described the patients mother to struggle with anxiety and depression, and the patients father as short tempered. These findings support a serious disruption of family milieu. For dimension 4B, recovery environment provides limited support (score 3). The patients parents have been participating in their daughters treatment but are noted to lack insight. One of patients two sisters has an eating disorder and has been in treatment. This suggests that there are some limitations to the support available in the environment. The patients 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) since previous IOP and outpatient treatment did not achieve complete remission of symptoms nor optimal control of symptoms. In addition, the patient has continued to self-harm while in RTC and she has endorsed passive suicidal ideation. 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. For dimension 6, the patient has been incompletely engaged in treatment (score 3) since her providers charted that she has self-harmed on several occasions while in the RTC and has been unable to talk to staff when having urges to self-harm. The patient remains ambivalent about stopping her self-harm behaviors. The patient is also noted to frequently isolate and withdraw instead of engaging in the RTC treatment milieu. The patient has been ambivalent, avoidant, and distrustful of 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. Moreover, the RTC services at issue are being provided in accordance with the generally accepted standards of mental health and substance use disorder care, are clinically appropriate in terms of type, frequency, extent, site, and duration, and are not primarily for the convenience of the patient or provider. For these reasons, the RTC services 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.