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

The parents of an enrollee has requested reimbursement for residential treatment center (RTC) services at RTC from 4/28/20 through 8/07/20.At issue in this case is whether RTC services at RTC from 4/28/20 through 8/07/20 were medically necessary to treat the patients medical condition. The Child and Adolescent Level of Care Utilization System (CALOCUS) provides a 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) 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, the patient met the criteria for RTC services at RTC provided from 4/28/20 through 8/07/20. With regard to risk of harm, the records support a score of 4. The patient was at serious risk of harm as he exhibited clear and persistent inability to maintain physical safety as evidenced by his repeated physically aggressive behaviors towards adults and peers while in the RTC. The patient has a history of aggressive behaviors in the community and this continued to be a challenge for him while in treatment. The records document that patient engaged in repeated physical aggression which required physical restraints to ensure safety. The patient has been suicidal in the past and overdosed once on his psychotropic medications which caused psychosis and led to an inpatient psychiatric stay.In terms of functional status, the records support a score of 4. The patient demonstrated serious functional impairment in that he had been physically and verbally aggressive while in a highly supportive therapeutic environment. The patient was also socially isolative. His limited social interactions were poor, as he would often antagonize peers. He struggled with cognitive rigidity. The patient exhibited significant emotion dysregulation, engaging in aggressive behaviors when any demands or expectations were placed on him. He also exhibited repeated and significant disruptive behaviors in the classroom while in the RTC.With regard to comorbidity, the records support a score of 3. The patient had significant comorbidity considering that he has two neurodevelopmental disorders, autism and ADHD. The patient has a history of medication-induced weight gain. He also struggles with insomnia for which he takes medication.In terms of level of stress of the recovery environment, the records support a score of 3. The patients recovery environment is moderately stressful given his longstanding school difficulties. His parents are divorced and live across the country from one another. The patient also struggles with role expectations for his developmental level.With regard to level of support of the recovery environment, the records support a score of 2. The patients recovery environment appears to be supportive as evidenced by parents who have repeatedly sought out mental health treatment for their son. The patients parents have also been participatory in their sons treatment.In terms of resiliency and treatment history, the records support a score of 5. The patient has shown negligible response to treatment and recovery management. He has an extensive history of mental health treatment dating back to the second grade when he first began meeting with a psychologist. He has undergone various psychiatric and psychological evaluations and has been treated with multiple psychotropic medications over the years. He has been treated in an inpatient psychiatric hospital, has participated in a partial hospital program (PHP) for four months and was treated in an outdoor behavioral health program for four months prior to being placed in the RTC.With regard to treatment acceptance and engagement, the records support a score of 4. The patient struggled to engage appropriately and willingly in treatment. He often blamed others for his problems and accepted little to no age-appropriate responsibility for his role in the development and perpetuation of his problems. He was often resistant and/or reluctant to participate in treatment, although this appeared to improve somewhat towards the end of his stay in RTC. Overall, the patient was largely non-collaborative in treatment.Thus, the patient has a total score of 25. These findings give the patient a composite score of 25, which is consistent with Level 5 Medically Monitored Residence Based Services. Per CALOCUS, the childs scores of 4 for risk of harm and functional status also support treatment at with Level 5 Medically Monitored Residence Based Services level of care. Therefore, RTC services at RTC from 4/28/20 through 8/07/20 were medically necessary to treat the patients medical condition.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 sub-specialty 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.