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. Findings:  The physician reviewer found that (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.For dimension 1, the patient has been at serious risk of harm (score 4) given her recent history of attempting suicide by overdose and she continued suicidal ideation while in treatment. The patient has engaged in self-harm since admission to RTC. The patient has not been consistently compliant with her meal plan. These factors support current suicidal ideation with either clear, expressed intentions and a past history of carrying out such behavior. The patient has expressed ambivalence about carrying out the safety plan. Signs of consistent deficits in ability to care for self. For dimension 2, the patient has demonstrated serious functional impairment (score 4) due to her inconsistent compliance with her meal plan, highly dysregulated behaviors at the table, maladaptive behaviors around eating, and poor relationships with her parents and siblings despite ongoing family therapy. These behaviors support a consistent failure to achieve self-care at a level appropriate to age and developmental level. For dimension 3, the patient has major comorbidity (score 4). The provider noted that the patient has chronic hip pain and urinary incontinence. On admission, she was noted to be bradycardic and orthostatic. Treatment summaries indicate that her orthostasis continued and although her bradycardia had resolved, she was now experiencing tachycardia. The patient has also reported dizziness, headaches, acid reflux, and constipation. Medical conditions are present that will adversely affect, or be affected by, the presenting condition. For dimension 4A, the patients recovery environment has been highly stressful (score 4) given her history of abuse. In addition, at least one of the patients siblings also struggles with anxiety and depression. The provider noted that there is parent-child conflict despite participation in ongoing family therapy. This supports serious disruption of family milieu with severe conflict, torment and/or physical/sexual abuse or maltreatment. For dimension 4B, the patients recovery environment provides limited support (score 3). The patient reports that her relationship with her parents and sisters is poor even though they have all been going to family therapy. The patient reports that she feels she will relapse on self-harming and restricting in her home environment, where she lacks support. The provider noted that repair work is occurring in family therapy, but family conflict continues to be a barrier to the patients discharge. Family caretakers demonstrate only partial ability to make necessary changes during treatment.For dimension 5, the patient has shown poor resiliency and response to treatment (score 4) considering her extensive treatment history in 2020 including outpatient, IOP, PHP, RTC, and psychiatric inpatient levels of care. This treatment history suggests that previous treatment has not achieved complete remission of symptoms or optimal control of symptoms even with intensive and repeated exposure to treatment. Attempts to maintain whatever gains that were attained in intensive treatment have limited success, even for limited time periods or in structured settings. For dimension 6, the patient has been incompletely engaged in treatment (score 3) since she has been able to engage in treatment during her residential stay but has consistently struggled with acting on urges of self-harm, complying with her meal plan, and abstaining from engaging in maladaptive behaviors during mealtimes. Acknowledges existence of problem, but resists accepting even limited age-appropriate responsibility for development, perpetuation, or consequences of problem. These findings give the patient a composite score of 26, which is consistent with medically monitored residence-based services. Moreover, the patients score of 4 on risk of harm, functional status, and comorbidities, which supports medically monitored residence-based services. Based on CALOCUS, the services are in accordance with the generally accepted standards of mental health care, clinically appropriate in terms of type, frequency, extent, site, and duration, and are not primarily for the benefit or convenience of the patient or provider. For these reasons, the RTC 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.