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

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for continued residential treatment center (RTC) services at a dual diagnosis (mental and substance abuse) facility that specializes in teenagers. 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 continued RTC services. For dimension 1, the patient has been at serious risk of harm (score 4) due to a significant substance use disorder. The patient required a visit to the emergency department in February 2021 due to acute intoxication on substances. The patient endorses use of Xanax and Molly, and his urinalysis was positive for amphetamines, benzodiazepines, and tetrahydrocannabidiol. The patient was recently discharged from inpatient psychiatric level of care for a similar presentation. The patient reportedly has written notes expressing suicidal ideation. Recent pattern of excessive substance use resulting in clearly harmful behaviors with no demonstrated ability of the patient or family to restrict use. For dimension 2, the patient has demonstrated serious functional impairment (score 4) given his history of suicidal ideation and recent psychosis in January 2021, which was likely related to substance use. The patient has not been successful in school. The patient also ran away in February 2021 and was found wandering the highway while intoxicated. This supports serious disturbances in physical function. For dimension 3, the patient has major comorbidities (score 4) considering his significant substance use posing a serious threat to his health and impeding recovery from his persistent depressive disorder. Uncontrolled substance use is present that poses a serious threat to health if unabated and impedes recovery from the presenting condition. For dimension 4A, the patients recovery environment is highly stressful (score 4). The provider noted that the patient has high levels of conflict with his parents, with episodes of screaming and shouting. The patient alleged that his parents are physically abusive. The patient has exhibited labile behaviors at home. Serious disruption of family and social milieu. For dimension 4B, the patients recovery environment provides limited support (score 3). The records document that his parents have been overwhelmed with the patients behaviors including severe defiance. The patient has experienced multiple codependent relationships with girlfriends. Family caretakers are seriously limited in ability to provide for the patients developmental, material, and emotional needs. For dimension 5, the patient has shown poor resiliency and response to treatment (score 4) due to his history of multiple inpatient stays, RTC, and outpatient therapy, with limited long-term gains. Treatment has also included medication trials. 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 he appears to externalize blame, with tendencies to tell providers what they want to hear, but not carry through on agreements. The patient also has a history of defiance, poor treatment insight, and poor motivation. Ambivalent, avoidant, or distrustful relationship with clinicians and other care providers. These findings give the patient a composite score of 26, which is consistent with medically monitored residence-based services. The patients scores of 4 on risk of harm and functional status also support Level 5 medically monitored residence-based services. Per CALOCUS, the patient also meets the requirements for Level 5C long-term medically monitored residence-based services. All told, the requested continued RTC services at a dual diagnosis (mental and substance abuse) facility that specializes in teenagers are medically necessary for treatment of this patient 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. Final Result: The reviewer determined that the requested services 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.