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

Nature of Statutory Criteria/Case Summary: The patient 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. For dimension 1, the patient was at serious risk of harm (score 4) due to property destruction and outbursts leading to police involvement. There was indication or report of significant impulsivity and physical aggression, with poor judgment and insight, and that were significantly endangering to self or others. Recent pattern of excessive substance use resulting in harmful behaviors with no demonstrated ability of family to restrict use, as evidenced by a motor vehicle accident that occurred while under the influence of cannabis. For dimension 2, the patient demonstrated serious functional impairment (score 4) given his to conflict with his parents, social withdrawal, and his lack of school attendance, even after being placed in an alternative school program. The patient showed significant withdrawal and avoidance of almost all social interaction. Moreover, the patient was unable to perform adequately even in a specialized school setting due to disruptive behavior, or inattentiveness. For dimension 3, the patient has significant co-morbidity (score 3), due to co-existence of cannabis use disorder with anxiety and depression. Recent substance use that has significant impact on the presenting condition has been arrested due to use of a highly structured or protected setting or through other external means. For dimension 4A, the patients recovery environment was mildly stressful (score 2) considering his family conflict. There were expectations for performance at home or school that created discomfort. For dimension 4B, the patients recovery environment was supportive (score 2) as evidenced by his parents active participation in treatment. The patients family were willing and able to participate in treatment if requested to do so and have capacity to effect needed changes. For dimension 5, the patient exhibited moderate or equivocal resiliency and response to treatment (score 3). 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 incompletely engaged in treatment (score 3). The records document that the patient acknowledged existence of problem, but resisted accepting even limited age-appropriate responsibility for development, perpetuation, or consequences of the problem. The patients minimization of the consequences of his cannabis abuse, and tendency to blame family conflict on his parents. These findings give the patient a composite score of 21, which is consistent with medically monitored community-based services. Due to the patients scores of 4 on risk of harm and functional impairment, the recommended level of care is Level 5 medically monitored residence-based services. Furthermore, the patient qualified for Level 5B intermediate stay medically monitored-residence based programs, due to significant disturbance in interpersonal interactions with consistent conflict or otherwise disrupted interactions with others, which may include impulsive or abusive behaviors as well as co-occurring substance use and mental health disorders and a lack of response to a lower level of care. Per CALOCUS, the length of stay for Level 5B usually does not exceed 60 days. The patients length of stay in residential treatment was below this 60-day threshold. Given these findings, the RTC 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.