Appeal type: Medical Necessity
Decision: Upheld 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 does not meet the criteria for RTC services.For dimension 1, the patient has been at significant risk of harm (score 3) due to multiple symptoms of depression and anger, with self-harm and suicidal ideation while in RTC in the earlier weeks. However, by the date of the denial, the patients symptoms were markedly decreased. No active suicidal or homicidal ideation, but extreme distress and/or a history of suicidal/homicidal behavior. For dimension 2, the patient has demonstrated moderate functional impairment (score 3) given the patients gains while in RTC, with improved ability to tolerate distress. The records note that the patient has a conflicted relationship with the patients parents but has been increasingly able to talk about concerns. 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 minor comorbidities (score 2) considering the diagnoses of depression, anxiety, gender dysphoria, parent-child problem, and amblyopia with a history of detached retina in one eye. Self-limited medical conditions are present that are not immediately threatening or debilitating and that have no impact on the presenting condition and are not affected by it. For dimension 4A, the patients recovery environment has been highly stressful (score 4). The records document a history of domestic violence. There continues to be concerns around a difficult, severe, and conflictual family system. The patient appears to easily become reactive and angry towards the patients parents. This supports a serious disruption of family and social milieu. For dimension 4B, the patients recovery environment has provided limited support (score 3) due to the patients parents entanglement in their own reactivity and enmeshment. The patient appears to still regress in family therapy and become angry, especially around topics surrounding electronics use. There is a history of domestic violence and severe conflict in the home. The family has limited ability to respond appropriately to the patients developmental needs and/or problems or is ambivalent toward meeting these needs or addressing these problems. For dimension 5, the patient has exhibited negligible resiliency and response to treatment (score 5). The provider reported that the patient has not shown improvement despite treatment at lower levels of care such as intensive outpatient program (IOP) and psychiatric hospitalizations as well as multiple medication trials, with ongoing struggles with suicidal ideation. Symptoms are persistent and functional ability shows no significant improvement despite intensive treatment exposure. For dimension 6, the patient has been constructive in treatment (score 2) since the providers have described the patient as engaged and making efforts in treatment, with significant improvement. The patient was reported to be applying many dialectical behavior therapy (DBT) skills, with observation of much brighter affect and ability to regulate. The patient was described to have an oftentimes bright affect and cooperative with treatment. Able to develop a trusting, positive relationship with clinicians and other care providers. These findings give the patient a composite score of 22, which is consistent with medically monitored community-based services. The RTC services were not clinically appropriate in terms of type, frequency, extent, site, and duration. Therefore, the RTC level of care services provided at Ascend Healthcare, LLC, were not medically necessary for treatment of the patients mental health or substance use disorder as defined in Health and Safety Code section 1374.72(a)(3)(A).Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. 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.