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 is at serious risk of harm (score 4) due to current suicidal ideation with either clear, expressed intentions and/or past history of carrying out such behavior. The patient has expressed ambivalence about carrying out the safety plan and/or her familys ability to carry out the safety plan is compromised. In this case, the patient has repeatedly expressed suicidal ideation while at the RTC and she stated a specific plan to overdose on Tylenol and Benadryl. She also has a history of a recent suicide attempt. For dimension 2, the patient has demonstrated serious functional impairment (score 4), due to serious deterioration of interpersonal interactions with consistent conflict or otherwise disrupted interactions with others, which may include impulsive or abusive behaviors. The patient reported conflict with her parents and sister at home. The patient reported that during one altercation, she stabbed her sister with a fork. At the RTC, the patient has had conflict with peers which led to suicidal ideation and leaving without permission from the facility. She has also been struggling in school. For dimension 3, the patient has minor comorbidities (score 2), due to reported exercise-induced asthma and pulmonary artery fistula. Self-limited medical conditions are present that are not immediately threatening or debilitating and that have no impact on the presenting condition and are not affected by it. For dimension 4A, the patients recovery environment has been moderately stressful (score 3) due to past sexual trauma, conflict at home, social isolation, and the disruptions caused by the pandemic. This supports disruption of family and social milieu. For dimension 4B, the patients recovery environment has been supportive (score 2) given her parents active participation in treatment and treatment planning. Family caretakers are willing and able to participate in treatment if requested to do so and have capacity to effect needed changes. For dimension 5, the patient has exhibited poor resiliency and response to treatment (score 4).  Previous treatment has not achieved complete remission of symptoms or optimal control of symptoms even with intensive and/or repeated exposure to treatment. In this case, the patients symptoms persisted after an extended stay in the hospital. For dimension 6, the patient has been incompletely engaged in treatment (score 3), due to her impulsive departure from the facility and continued self-harm while at the RTC. Ambivalent, avoidant, or distrustful relationship with clinicians and other care providers. These findings give the patient a composite score of 22, which is consistent with medically monitored residence-based services. Per CALOCUS, the patients scores on risk of harm and functional status also support Level 5 medically monitored residence-based services. In addition, the patient qualifies for Level 5B intermediate stay medically monitored residence-based services, due to her continued suicidal ideation, disrupted interpersonal interactions, and lack of response to previous treatment. Per CALOCUS, the length of stay at Level 5B usually does not exceed 60 days. Accordingly, RTC services for up to 60 days were and are medically necessary for treatment of this patient. Moreover, the RTC services are in accordance with the generally accepted standards of mental health and substance use disorder care, clinically appropriate in terms of type, frequency, extent, site, and duration, and not primarily for the convenience of the patient or provider. Therefore, 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.