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

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for admission to inpatient level of care, or in the alternative, admission to a residential treatment center (RTC). The American Association of Community Psychiatrists Level of Care Utilization System (CALOCUS) provides a reliable framework for determining the appropriate level of care for adults 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) medical, addictive 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, the patient meets the criteria for RTC services. For dimension 1, the patient has been at serious risk of harm (score 4) with homicidal and possible suicidal ideation. The records document that the patient has no prior history of suicide attempts or self-harm behaviors. However, the patient exhibits evidence of clear and persistent inability, given his developmental stage, to maintain physical safety and care adequately for himself by continuing to exercise against medical advice and to engage in dietary restriction. The records also indicate that the patient has not been compliant with medications indicating poor judgment. Although not suicidal, his behaviors place him at serious risk of harm. For dimension 2, the patient has demonstrated moderate functional impairment (score 3) given his conflictual relationships with his family members due to his eating disordered behaviors and OCD symptoms. He becomes frustrated and argumentative when parents attempt to enforce his meal plan. Furthermore, his eating disorder has interfered with his relationships with friends. Conflicted, withdrawn, or otherwise troubled relationships with peers, adults, and family, but without episodes of physical aggression. For dimension 3, the patient has major comorbidities (score 4) given his diagnosis of allergic rhinitis, which has not responded to several medications. In addition, the patient has experienced cardiac and metabolic sequalae of his eating disorder including bradycardia, anemia, and leukopenia. The patients psychiatric symptoms are adversely affecting his health and have seriously impaired his recovery and functioning. 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) due to conflict with parents regarding his dietary restriction and excessive exercise. Furthermore, there is disagreement between his parents of how to best address patients eating disordered behaviors with his father taking a consequence-based approach. This supports serious disruption of family or social milieu. For dimension 4B, the patients recovery environment provides limited support (score 3) since the patients parents are participating in treatment and appear to be willing to make changes in their parenting practices to better their relationship with the patient. The records indicate that the patients father struggles with frustration, tantrums, and irritability towards the patient. Family caretakers demonstrate only partial ability to make necessary changes during treatment. For dimension 5, the patient has shown moderate or equivocal resiliency and response to treatment (score 3). The records document a prior medical hospitalization and several years of outpatient treatment. The patient is currently in an eating disorder IOP. Although the patient has gained weight while in the IOP, the provider charted that the patient has shown limited ability to follow through with treatment recommendations as evidenced by continued compulsive exercising at every opportunity. Previous experience in treatment at low level of intensity has not been successful in relief of symptoms or optimal control of symptoms. For dimension 6, the patient has been non-collaborative in treatment (score 4). The records indicate that outside of the treatment setting, the patient continues to engage in eating disordered behaviors such as hiding and spitting out food, overexercise, and non-compliance with medication. The patient accepts no age-appropriate responsibility role in development, perpetuation, or consequences of the problem. These findings give the patient a composite score of 25, which is consistent with Level 5 medically monitored residence-based services. Per CALOCUS, the patients scores of 4 for risk of harm and comorbidity support treatment at Level 5 medically monitored residence-based services level of care. Moreover, RTC services are in accordance with the generally accepted standards of mental health and substance use disorder care, clinically appropriate in terms of type, frequency, extent, site, and duration, and not primarily for the convenience of the patient or provider. For these reasons, admission to a RTC is medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested services 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.