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

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for a 35-day Residential Treatment Center (RTC) program that specializes in obsessive compulsive disorder (OCD) and depression that offers the following services: individual therapy for one hour daily; weekly evaluation with a psychiatrist (via telehealth during pandemic); weekly evaluation with a psychologist (via telehealth during pandemic); group therapy with multiple sessions per day for a total of six hours including cognitive behavior therapy (CBT), dialectical behavior therapy (DBT), mindfulness-based CBT, interpersonal therapy, and equine therapy (with each group approximately one hour); and family therapy for one hour per week (via telehealth).The Child and Adolescent Level of Care Utilization System (CALOCUS) provides a framework for determining the clinically appropriate level of care for a child or adolescent in 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 (Astressors, and B-supports); (5) resiliency and treatment history; and (6) treatment acceptance and engagement. The composite score is then used to determine the level of care needed. In this case, CALOCUS scores are as follows:For dimension 1  Risk of Harm. This dimension assesses potential for harm to self or others, or having harm inflicted upon them. The records note that the patient has had multiple symptoms of depression and anxiety with impulsive self-harm and suicidal statements. The patient has exhibited severe emotional lability. [Score 2  Some Risk of Harm]For dimension 2  Functional Status. This dimension assesses the degree to which a person is able to fulfill responsibilities for a given age level. The records note that the patient will go days without showering, that she is not doing well in school, and that she is exhibiting self-harm when triggered. The patient has compulsions to hit herself, and most recently, she has been refusing to eat in front of others. The patient has bouts of severe agitation and mood lability with multiple depressive and anxiety symptoms, and she is struggling in school. [Score 4  Serious Functional Impairment]For dimension 3  Comorbidity. This dimension assesses the co-existence of disorders across four domains (psychiatric, substance use, medical or developmental) that may complicate the course of treatment. The patient has clear obsessive compulsive disorder (OCD) along with depressive and anxiety symptoms with possible attention deficit hyperactivity disorder (ADHD) issues. The patient appears to have possible learning issues given her Individualized Education Program (IEP) and school struggles. [Score 2  Minor Co-Morbidity]For Recovery Environment dimension 4A  Stress. This dimension assesses the stressors in the environment, social circumstances, and interpersonal relationships. The patients recovery environment is highly stressful. It appears that her family is having significant difficulties maintaining a therapeutic and supportive environment. [Score 4  Highly Stressful Environment]For Recovery Environment dimension 4B  Support. This dimension assesses the presence of family and social support to augment the recovery environment. The patients parents are overwhelmed and at a loss as to how to manage a severely reactive, depressed, and anxious child. The patients parents have had difficulties carrying through with provider recommendations despite attempts to be supportive. [Score 3  Limited Support in Environment]For dimension 5  Resiliency and Treatment History. This dimension assesses success or failure to make use of treatment and natural support that fosters resilience. The patient has had a negligible response to outpatient teleconference appointments, with her symptoms appearing to worsen. [Score 5  Negligible Response to Treatment]For dimension 6  Treatment Acceptance and Engagement. This dimension assesses a persons understanding of their illness and treatment, and their ability and willingness to engage in the treatment process. The patient has not been willing to engage online with providers productively, and she largely refuses this approach. In addition, the patients therapist brought up referral to a middle school group, and the patient stated that she did not want to attend any groups at this time. [Score 3  Incompletely Engaged]These findings give the patient a composite CALOCUS score of 23, which is consistent with Level Five: Medically Monitored Residence-Based Services. The patient has had severe bouts of mood and behavioral dysregulation at home including self-harm and suicidal statements as well as physical aggression towards her younger brother such as kicking him. There are concerns for screaming, yelling, and defiance. The patients OCD symptoms have been worsening. Overall, given the patients presentation, Level 5 Residential Treatment Center services are warranted for safety and stabilization. The patient would benefit from learning more regulation skills, and her parents appear to be in need of further support and psychoeducation regarding ways to support the patient. The patient would benefit from more intensive medical management and individual and family therapy. Further evaluation of other possible co-morbid concerns is indicated such as ADHD and learning disabilities, and psychological testing likely would be informative. Accordingly, the requested 35-day Residential Treatment Center (RTC) program that specializes in Obsessive Compulsive Disorder (OCD) and Depression is medically necessary to treat the patients condition (OCD, depression, and suicidal ideation).Final Result: The reviewer determined that the requested services are medically necessary to treat the patient's 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.