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. Findings:  The physician reviewer found that 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) due to chronic suicidal ideation, with plan, without any prior attempts. Suicidal ideation continued at the RTC. Significant current suicidal ideation with some intent and plan, with an ability for the adolescent and her family to contract for safety and carry out a safety plan. The adolescent expresses some reason not to carry out such behavior. For dimension 2, the patient demonstrated serious functional impairment (score 4) given her conflict with her mother and brother, social withdrawal and isolation, and multiple school failures. 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 had no reported comorbidities (score 1). She is in good physical health, with no developmental disorders or history of substance abuse. No evidence of medical illness, substance abuse, developmental disability, or psychiatric disturbances apart from the presenting condition. For dimension 4A, the patients recovery environment was mildly stressful (score 2) considering the stress related to family conflict and the changes related to the pandemic. Significant transition requiring adjustment, such as change in household members, or new school or teacher. For dimension 4B, the patients recovery environment was supportive (score 2) due to her parents participation in family therapy 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 exhibited moderate or equivocal resiliency and response to treatment (score 3), due to lack of response to outpatient therapy and two different medication trials. Previous experience in treatment at low level of intensity has not been successful in relief of symptoms or optimal control of symptoms. For dimension 6, the patient was constructive in treatment (score 2), due to her cooperation with treatment at the RTC. The patient was able to develop a trusting positive relationship with clinicians and other care providers. These findings give the patient a composite score of 17, which is consistent with high-intensity community-based services. Given the patients scores of 3 on risk of harm and 4 on functional impairment, the patient met the criteria for Level 5, medically monitored residence-based services. Furthermore, the patient qualified for Level 5B, intermediate stay medically monitored residence-based services. In this case, the patient reported suicidal ideation prior to RTC admission, and continued to report suicidal ideation at the RTC and she has a history of self-harm. Per CALOCUS, the length of stay in RTC at level 5B usually does not exceed 60 days. In this case, the patient participated less than 30 days of treatment at the RTC level. Therefore, the RTC level of care 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.