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, this patient met the criteria for RTC services. For dimension 1, the patient was at serious risk of harm (score 4), due to her recent suicidal ideation with plan to hang herself or cut her wrists, with past history of suicide attempt and self-harm. Also, the patients mother expressed concern about being able to keep the patient safe at home. Current suicidal ideation with clear, expressed intentions and past history of carrying out such behavior. For dimension 2, the patient demonstrated moderate functional impairment (score 3), given her decline in academic performance and neglect of personal hygiene. Self-care deteriorated below usual or expected standards on a frequent basis. The patients school behavior deteriorated to the point of the patient was at risk for placement in an alternative school program. For dimension 3, the patient has significant co-morbidities (score 3), with a diagnosis of Hashimotos thyroiditis, which may have affected her physical functioning and weight. Medical condition was present that may adversely affect, or be adversely affected by, the presenting condition. For dimension 4A, the patients recovery environment was moderately stressful (score 3). The records document that the patients grandmother passed, and she also reported stress caused by the pandemic as well as history of abuse by her ex-boyfriend. This supports a disruption of family and social milieu. For dimension 4B, the patients recovery environment was supportive (score 2), considering her parents participation in family therapy and treatment planning. Family caretakers were willing and able to participate in treatment if requested to do so and had capacity to effect needed changes. For dimension 5, the patient has shown poor resiliency and response to treatment (score 4). The provider noted that the patients depressive symptoms and suicidality persisted despite multiple hospitalizations, IOP and outpatient therapy, and multiple 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 was constructive in treatment (score 2), due to her cooperation with her treatment regimen while at the RTC. The patient was able to develop a trusting, positive relationship with clinicians and other are providers. These findings give the patient a composite score of 21, which is consistent with medically monitored community-based services. Per CALOCUS, the patients score of 4 on risk of harm and scores of 3 on functional status and comorbidities, supports treatment at Level 5, medically monitored residence-based services. Furthermore, the patient qualified for Level 5B, intermediate stay medically monitored residence-based services. The patient experienced some suicidal or homicidal ideation with some ambivalence or was highly distressed with some history of harm to self or others. Impulsivity may be present and the risk of engaging in destructive behaviors is significant in an unstructured environment. This was demonstrated by the patients recent suicidal ideation with plan and history of suicide attempt and self-harm. Her mother had also stated that she did not feel she could keep the patient safe at home. Per CALOCUS, treatment at Level 5B usually does not exceed 60 days. In this case, the patient participated in 11 days of RTC, which is within the length of stay guidelines for Level 5B. Therefore, the mental health RTC services were medically necessary for 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.