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. Findings:  The physician reviewer found that 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 recent pattern of excessive substance use resulting in clearly harmful behaviors with no demonstrated ability of the patient or family to restrict use. This was demonstrated by the patients escalating substance use despite several weeks of IOP treatment, as well as a suicidal threat made while intoxicated, and running away from home. For dimension 2, the patient demonstrated moderate functional impairment (score 3) given conflict with parents and stepmother, truancy. The patient made recent gains while participating in treatment in a structured, protected, or enriched service. For dimension 3, the patient has significant comorbidities (score 3) considering significant recent substance use that was arrested in the controlled and protected setting of the RTC. The patient is also noted to have diagnoses of post-traumatic stress disorder (PTSD), depression, and anxiety. Recent substance use that had significant impact on the presenting condition was arrested due to use of highly structured or protected setting or through other external means. For dimension 4A, the patients recovery environment was moderately stressful (score 3) due to history of stalking and attempted abduction, as well as conflict with his parents. This supports a disruption of family and social milieu. For dimension 4B, the patients recovery environment was supportive (score 2) due to parental participation in treatment 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 exhibited moderate or equivocal resiliency and response to treatment (score 3) due to continued escalation of symptoms after outpatient and IOP treatment. The patient demonstrated continued behavioral problems including substance abuse and running away from home, as well as persistent depressive, anxiety, and PTSD symptoms after several weeks of IOP treatment. Previous experience in treatment at low level of intensity was not successful in relief of symptoms or optimal control of symptoms. For dimension 6, the patient was constructive in treatment (score 2). The provider charted that the patient was an active participant in treatment. The patient was able to develop a trusting, positive relationship with clinicians and other care providers. These findings give the patient a composite score of 20, which is consistent with Level 4 medically monitored community-based services. Per CALOCUS, the patients score on risk of harm supports Level 5 medically monitored residence-based services. Furthermore, the patient qualified for Level 5B intermediate stay medically monitored-residence based services, since recent gains and stabilization in functioning were achieved while participating in a highly structured, protected, and enriched service and substance use was temporarily arrested due to use of a highly structured or protected setting. Per CALOCUS, the length of stay at Level 5B usually does not exceed 60 days. The patients  RTC stay was less than 30 days, and within the window for an intermediate length of stay. All told, the RTC level of care 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.