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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Inpatient Behavioral Health services.The Child and Adolescent Level of Care Utilization System (CALOCUS) provides a reliable 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 (a. stressors 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.For dimension 1- Risk of Harm. This dimension assesses potential for harm to self or others. The patient had serious risk of harm, due to significant impulsivity and/or physical or sexual aggression, with poor judgment and insight, and that is/are significantly endangering to self or others. This was demonstrated by the patient's impulsivity prior to admission (jumping out of a second story window for a thrill, resisting transport to the inpatient hospital), and the sole incident involving property destruction during his inpatient stay, when he broke a lock on a door, postured at staff, and turned over a food cart in anger. The patient also had a history of suicide attempt at age 13. [Score 4  serious]For dimension 2  Functional Status. This dimension assesses the degree to which a person is able to fulfill social responsibilities, interacts with others, and maintains physical functioning and capacity for self-care. The patient had serious functional impairment, due to serious deterioration of interpersonal interactions with consistent conflict or otherwise disrupted interactions with others, which may include impulsive or abusive behaviors. This was evidenced by the patients outburst after family therapy. Parents also noted difficulty managing the patient's behavior at home prior to admission. The patient also had a history of fighting at school. However, the patient did not display the extreme deterioration in interactions that would have constituted severe functional impairment. [Score 4  serious] For dimension 3  Comorbidity. This dimension assesses potential complications in the course of treatment due to acuity or disability related to co-occurring medical illness, substance use disorder, or psychiatric disorder. The patient had significant co-morbidity due to recent substance use that had a significant impact on his presenting condition and that had been arrested due to use of a highly structured or protected setting or through other external means. The patient had a history of abuse of multiple substances, with recent alcohol, marijuana, and acid use. He also had a learning disability. [Score 3  significant]For Recovery Environment dimension 4A- Stress. This dimension assesses the stressors in the patients environment, social circumstances, and interpersonal relationships. The patient appeared to have had a moderately stressful environment, due to a history of bullying, a potential for fighting with peers at school, conflict with his parents, as well as the transition to a different school that fall. [Score 3  moderately stressful]For Recovery Environment dimension 4B- Support. This dimension assesses the presence of family and social support to augment the patients recovery environment. The patient had a supportive environment, as his parents participated in treatment and treatment planning. [Score 2 - supportive]For dimension 5- Treatment and Recovery History. This dimension assesses how past experiences with treatment and recovery might indicate how the patient might respond in the future. The patient had poor resiliency, as his previous treatment had not achieved complete remission of symptoms or optimal control of symptoms even with intensive and/or repeated exposure to treatment. The patient had continued to struggle with impulsivity, mood and anxiety after three months of wilderness treatment. [Score 4- poor response]For dimension 6  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 had incomplete engagement. This was demonstrated by his minimization of his behaviors and symptoms. [Score 3- incomplete engagement]These findings give the patient a composite CALOCUS score of 23, which is consistent with Level 5: Medically Monitored Residence-Based Services. However, the patient was receiving care in an inpatient psychiatric unit, which is classified as Level Six: Medically Managed Residence/Based Services. The record does not indicate that patient's symptoms required daily psychiatric monitoring, constant nursing care, and the other intensive services provided in a hospital setting. Other than one anger outburst, which resulted in property destruction but no harm to the patient or anyone else, the patient demonstrated the ability to maintain safety during his hospital stay and he generally cooperated with daily activities and expectations. During the period under review, the patients needs could have been safely met in a residential treatment setting. Accordingly, the Inpatient Behavioral Health services at issue were not medically necessary to treat the patients condition.Final Result: The reviewer determined that the service at issue were not medically necessary to treat the patients medical condition. Therefore, the Health Plans denial should be upheld.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.