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

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement and prospective authorization and coverage 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 meets the criteria for residential eating disorder treatment services. For dimension 1, the patient has been at serious risk of harm (score 4), given her consistent deficits in her ability to perform self-care. The patient was restricting her food and fluid intake at home and over exercising against her providers recommendations. Over the past week, she reportedly escalated to purging behaviors. There are signs of consistent deficits in ability to care for self and use environment for safety. For dimension 2, the patient has shown moderate functional impairment (score 3), due to problems with self-care, conflict with her parents regarding food, and anxiety related to school. She has demonstrated gains in the protected setting of the facility, and consumed 100% of her meals in this setting, but has not been maintaining those gains at home. Recent gains and/or stabilization in functioning have been achieved while participating in treatment in a structured, protected, and/or enriched service. For dimension 3, the patient has significant co-morbidities (score 3), due to recent rapid weight loss and other physical symptoms resulting from her restricting of food and fluids. These symptoms are concerning even in the presence of a normal body mass index (BMI). Medical conditions are present that may adversely affect, or be adversely affected by, the presenting condition. For dimension 4A, the patients recovery environment has been mildly stressful (score 2), due to stress related to family conflict and the changes brought on by the pandemic. This supports significant transition requiring adjustment, such as change in household members, or new school or teacher.For dimension 4B, the patients recovery environment has been supportive (score 2). The records document her parents participation in treatment and treatment planning, with some struggles managing he patients meals and snacks at home. Family caretakers are willing and able to participate in treatment if requested to do so and have capacity to effect needed changes. For dimension 5, the patient has exhibited moderate resiliency and response to treatment (score 3), due to persistence and escalation of disordered eating, over exercising, and onset of purging after more than two weeks of treatment. The patient has demonstrated an inconsistent or equivocal capacity to deal with stressors and maintain normal development.For dimension 6, the patient has been incompletely engaged in treatment (score 3), due to her difficulty in following treatment recommendations, as demonstrated by continued restricting, over exercising, and recent purging at home. The patient minimizes or rationalizes distressing behaviors and consequences. These findings give the patient a composite score of 20, which is consistent with medically monitored residence-based services. Furthermore, the patient qualifies for Level 5B, intermediate stay medically monitored residence-based services since prior treatment, particularly in lower levels of care, has not been successful, and child has developed limited resilience. In this case, the patient has not made progress in consuming meals and snacks at home, has continued to exercise beyond treatment recommendations, and has started to purge, while participating in treatment. Per CALOCUS, the length of stay at Level 5B usually does not exceed 60 days. Therefore, residential eating disorder treatment services were and are medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were and are 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.