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 clinically managed residential services that provide 24-hour living support and structure with available trained personnel, offers at least five hours of clinical services a week, and is staffed by designated addiction treatment, mental health, and general medical personnel, and provides a range of services in a 24-hour living support setting, and/or provision of these services at a closed and secured facility. 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. Based on CALOCUS criteria, this patient meets the criteria for residential treatment. The patient is at serious risk of harm to himself and others (score 4) as evidenced by past chronic suicidality, including while being treated at the RTC level of care. In addition, the patient has exhibited aggressive and impulsive behavior after nearly eight months of RTC services. The provider noted concern regarding the patients past history of substance abuse. The patient has demonstrated moderate functional impairment (score 3) due to his ongoing conflict with his mother and recent gains while in RTC. The patient has no significant comorbidities (score 1). The patients recovery environment is moderately stressful (score 3) as evidenced by parental conflict and custody dispute. The patients recovery environment is supportive (score 2) due to his parents participation in family therapy and his mothers attempts to secure appropriate treatment for the patient. The patient has shown poor response to treatment (score 4) based on continued symptoms despite multiple prior hospitalizations and wilderness treatment. The patient has reportedly made gradual progress while at the current RTC facility. The patient has been incompletely engaged in treatment (score 3) due to his minimization of his need for treatment and difficulty accepting responsibility for his behavior. This gives the patient a composite score of 20, which meets the criteria for medically monitored community-based services. However, given the patients score of 4 on risk of harm, the appropriate level of care is Level Five, medically monitored residence-based services. Thus, clinically managed residential services that provide 24-hour living support and structure with available trained personnel, offers at least five hours of clinical services a week, and is staffed by designated addiction treatment, mental health, and general medical personnel, and provides a range of services in a 24-hour living support setting are medically necessary for treatment of this patient. However, the patient is not at Level Six, which requires a locked facility. Medically necessary care at Level 5C can be provided at a facility offering long-term residential treatment. Given the patients lack of response to prior treatment at higher levels of care, a facility offering a treatment program of several months in duration is appropriate. All told, provision of these services at a closed and secured facility is not medically necessary for treatment of this patient. Final Result: The reviewer determined that a portion of the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially 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.