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, the patient met the criteria for RTC services.For dimension 1, the patient was at serious risk of harm (score 4) due to a history of aggressive behaviors, which has largely been directed towards his parents, but he has also been aggressive at school in the past. He is described as highly impulsive and lacking in insight. The provider noted that the patient does not endorse suicidal ideation nor is there a history of suicidal behavior. Given the patients history of significant impulsivity, aggression, and lack of insight, the patients risk of self-harm was estimated to be significantly endangering to self and others. For dimension 2, the patient demonstrated serious functional impairment (score 4) considering the patients problematic and at times aggressive interactions with peers, which continued throughout RTC, continued struggles with authority figures, chronic conflict with parents, and legal consequences for his behavioral issues. Records note that even towards the end of his RTC stay, he struggled with respecting his teachers and exhibiting appropriate behaviors in school. The records support that the patient was unable to perform adequately even in a specialized school setting due to disruptive behavior or inattentiveness. The patients attendance may have been sporadic, and the patient has multiple academic failures. For dimension 3, the patient has minor comorbidities (score 2), given the presence of multiple psychiatric diagnoses but no substance abuse or physical health comorbidities. The records document that transient, occasional, stress-related psychiatric symptoms were present that had no discernable impact on the patients presenting condition. For dimension 4A, the patients recovery environment was moderately stressful (score 3), given the longstanding and ongoing conflict between the patient and his parents. The patient also experienced difficulties with his peers. Furthermore, there was a disruption in the patients social milieu due to COVID-19. The records support a disruption of family and social milieu. For dimension 4B, the patients recovery environment provided limited support (score 3). The provider noted that the patients parents were supportive, but they experienced difficulty in implementing a structured setting for the patients return home. The patients family demonstrated only partial ability to make necessary changes during treatment. For dimension 5, the patient exhibited poor resiliency and response to treatment (score 4). The records document that previous treatment included RTC and an intensive outpatient program, neither of which achieved complete remission of symptoms nor optimal control of symptoms. The patients symptomatology has persisted despite multiple treatment attempts at several levels of care. Previous treatment has not achieved complete remission of symptoms or optimal control of symptoms even with intensive and/or repeated exposure to treatment. For dimension 6, the patient was non-collaborative in treatment (score 4) and struggled to take accountability for his actions and problems. Even at the time of discharge, the patient superficially engaged with his providers. The patient accepted no age-appropriate responsibility for his role in the development, perpetuation, or consequences of the problem. These findings give the patient a composite score of 24, which is consistent with Level 5, medically monitored residence-based services. Per CALOCUS, the patients scores of 4 for risk of harm and functional status also support treatment at Level 5, medically monitored residence-based services level of care. Moreover, the RTC services were 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. For these reasons, the psychiatric RTC services were medically necessary for the 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.