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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for residential treatment center (RTC) services. The American Association of Community Psychiatrists Level of Care Utilization System (CALOCUS) provides a reliable framework for determining the appropriate level of care for adults 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) medical, addictive 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 the first portion of the admission. For dimension 1, the patient was at serious risk of harm (score 4) due to expressed thoughts of self-harm without a history of suicidal behaviors. The patient has a history of using cannabis and alcohol to the point of inebriation. The provider noted that the patient engaged in aggressive and destructive behaviors. Indication or report of significant impulsivity and physical aggression, with poor judgment and insight, and that were significantly endangering to self or others. However, by the second portion of the admission, the patient was at some risk of harm (score 2) given her progress with behavioral issues. The patient continued to struggle with intermittent mood dysregulation, but she was abstinent from substances since admission to RTC. Past history of fleeting suicidal thoughts or impulses, with no current ideation, plan or intention and no significant distress. For dimension 2, the patient demonstrated serious functional impairment (score 4) given the severity of her psychiatric symptoms. The patient was unable to function in multiple domains including school and interpersonal relationships. She was inconsistent with attending school and completing homework despite having an individualized education program (IEP) and she experienced problems with peer relationships. The provider reported that the patient demonstrated frequent anger outbursts accompanied by verbal aggression and property destruction. The patient showed serious deterioration of interpersonal interactions with consistent conflict or otherwise disrupted interactions with others, which included impulsive and abusive behaviors. The patient was unable to perform adequately even in a specialized school setting due to disruptive behavior, or inattentiveness. School attendance was sporadic. By the second portion of the admission, the patient demonstrated moderate functional impairment (score 3) given her improved school attendance, engagement and academic performance. The patient continued to struggle with mood dysregulation and enmeshment with her mother. Recent gains in functioning were achieved while participating in treatment in a structured, protected and enriched service. For dimension 3, the patient had significant comorbidities (score 3) considering her history of cannabis and alcohol use to the point of inebriation. The patient is also noted to have sleep difficulties. Sleep difficulties can be caused by depression and anxiety, and conversely, can exacerbate depression and anxiety. A medical condition was present that may have adversely affected, or been adversely affected by, the presenting condition. By the second portion of the admission, the patient had minor comorbidities (score 2) given her history of sleep difficulties, which was treated with quetiapine with some improvement. In September 2020, she reported to her provider that she was sleeping well. There was no reported use of substances during RTC stay, which suggests abstinence of at least eight months. The patient actively worked on a relapse prevention plan. Self-limited medical condition was present that was not immediately threatening or debilitating and had no impact on the presenting condition and was not affected by it. For dimension 4A, the patients recovery environment was moderately stressful (score 3). The provider documented that the patients mother has a mental illness. The patient and her mother were enmeshed, yet the patient struggled to maintain friendships. School was a major source of stress for the patient. These factors support a disruption of family and social milieu. By the second portion of the admission, the patient the patients recovery environment was mildly stressful (score 2) considering her mothers mental illness and her unhealthy relationship with her mother. However, progress in the mother-daughter relationship was made in RTC. The patient and her mother reported improvement in their communication, which helped to mitigate relationship stressors. Somewhat inadequate material resources or threat of loss of resources due to parental underemployment, separation, or other factor. For dimension 4B, the patients recovery environment provided limited support (score 3) due to her parents ability to recognize that there were problems, and they were willing to participate in treatment. However, support from school and the community resources were inadequate to fully compensate for unmet academic and emotional needs, which suggests limited support in her recovery environment. The patients family had limited ability to respond appropriately to the patients developmental needs and problems or was ambivalent toward meeting these needs or addressing these problems. By the second portion of the admission, the patients recovery environment continued to provide limited support (score 3). The communication between the patient and her mother improved during treatment, but enmeshment remained an ongoing issue. For dimension 5, the patient has exhibited poor resiliency and response to treatment (score 4). The patient has been in outpatient treatment since elementary school without significant progress. Prior treatment has also included RTC for 45 days in 2018, PHP for approximately five weeks in 2018, and an IOP for an unknown period of time. The patient has demonstrated frequent evidence of innate vulnerability under stress and difficulty resuming progress toward expected developmental level. Previous treatment has not achieved complete remission of symptoms or optimal control of symptoms even with intensive and repeated exposure to treatment. By the second portion of the admission, the patient showed moderate or equivocal resiliency and response to treatment (score 3) given the patients progress in RTC with substantial completion of her treatment goals. The patient was able to transition successfully and accept change in routine most of the time with moderate intensity support.