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

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement for residential treatment (RTC) services.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) developmental, medical, substance use and psychiatric comorbidity; (4) recovery environment (Astressors, and B-supports); (5) resiliency and treatment history; and (6) treatment acceptance and engagement. The composite score is then used to determine the level of care needed.For dimension 1  Risk of Harm. This dimension assesses the patients potential for harm to self or others, or having harm inflicted upon them. The patient may be scored as having a serious risk of harm, due to signs of consistent deficits in her ability to care for herself and/or use her environment for safety. This was demonstrated by the patient's continued struggles with eating and her need for supervision and monitoring during and after meals and snacks. [Score 4  Serious Risk of Harm]For dimension 2  Functional Status. This dimension assesses the degree to which a patient is able to fulfill responsibilities and be capable of maintaining stable relationships with others relative to their baseline and others of their age level. The patient may be scored as having moderate functional impairment, due to conflict with her mother, disordered eating, and gains made in the structured setting of the RTC. [Score 3  Moderate Functional Impairment]For dimension 3  Comorbidity. This dimension assesses the co-existence of disorders across four domains (psychiatric, substance use, medical or developmental) that may complicate the course of treatment. The patient may be scored as having no co-morbidity, as she did not have a developmental disability, she was medically stable at the RTC, and she also denied significant substance use. [Score 1  No Co-Morbidity]For dimension 4A  Recovery Environment  Stress. This dimension assesses the stressors in the patients environment, social circumstances, and interpersonal relationships. The patient may be scored as having a mildly stressful environment due to conflict with her mother and disruptions caused by the COVID-19 pandemic. [Score 2  Mildly Stressful Environment]For dimension 4B  Recovery Environment  Support. This dimension assesses the presence of family and social support to augment the patients recovery environment. The patient may be scored as having a supportive environment due to her mother's active participation in treatment. [Score 2  Supportive Environment]For dimension 5  Resiliency and Treatment History. This dimension assesses the patients success or failure to make use of treatment and natural support that fosters resilience. The patient may be scored as having a moderate or equivocal resiliency and/or response to treatment as a result of recent gains and/or stabilization that had been achieved while she participated in a structured, protected, and/or enriched service. The patient had gained weight and adhered to her meal plan in the hospital and the RTC, which resulted in weight gain and improved overall health. [Score 3  Moderate or Equivocal Resiliency and/or Response to Treatment]For dimension 6  Treatment Acceptance and Engagement. This dimension assesses a patients ability to form therapeutic relationships within developmental constraints. The patient may be scored as having constructive treatment acceptance and engagement due to her active participation in treatment. [Score 2  Constructive]These findings give the patient a composite CALOCUS score of 17, which is consistent with Level 3: High Intensity Community Based Services. The patients score of 4 in the Risk of Harm dimension, however, automatically qualifies her for Level Five: Medically Monitored Residence-Based Services. Furthermore, the patient qualifies for Level 5B: Intermediate Stay Medically Monitored Residential Programs, as her recent gains and/or stabilization in functioning had been achieved while participating in treatment in a highly structured, protected, and/or enriched service. The patient had made progress toward her goals in the setting of the RTC and previously had struggled while in less intensive care. Per CALOCUS, the usual length of stay at Level 5B is up to 60 days. In this case, the patient participated in residential treatment for about 6 weeks, or 42 days, which is well within this window. It should also be noted that the patient was to be discharged to a virtual PHP program, which would not be able to offer the same level of support and monitoring of meals and snacks that would be provided in an in-person PHP program. The patient's prior severe restricting behaviors had placed her health at risk. Continuing the RTC level of care until she was both medically stable and emotionally ready to manage her eating more independently was reasonable. Therefore, the residential treatment (RTC) services at issue were medically necessary for the patients medical condition.Final Result: The reviewer determined that the services at issue were medically necessary for 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.