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 psychiatric 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 meets the criteria for RTC services. For dimension 1, the patient has been at serious risk of harm (score 4) due to recent involuntary hospitalization for active suicidal ideation with intent and plan, as well as continued suicidal ideation at the RTC. Although the patients suicidal thoughts have reportedly decreased during the current RTC admission, return to a less-structured, less supportive, and more socially isolated home environment would likely place the patient at risk of a recurrence of active suicidal ideation. The records support current suicidal or homicidal ideation with clear, expressed intentions and past history of carrying out such behavior. The patient has expressed ambivalence about carrying out the safety plan and his familys ability to carry out the safety plan is compromised.For dimension 2, the patient has demonstrated moderate functional impairment (score 3) given his conflicted relationship with his parents, and recent loss of peer support due to break up with romantic partner and conflict with close friends. The patient is experiencing conflicted, withdrawn, or otherwise troubled in relationships with peers, adults, and/or family, but without episodes of physical aggression. For dimension 3, the patient has no reported comorbidities (score 1) due to the absence of substance abuse, medical issues, and developmental disorders. There is no evidence of medical illness, substance abuse, developmental disability, or psychiatric disturbances apart from the presenting condition.For dimension 4A, the patients recovery environment has been moderately stressful (score 3) due to conflict with parents over gender identity. There has been a disruption of family and social milieu.For dimension 4B, the patients recovery environment provides limited support (score 3) since the patients primary caretakers demonstrate only partial ability to make necessary changes during treatment. This is demonstrated by his mothers struggles to accept patients gender identity, preferred pronouns, and preferred name.For dimension 5, the patient has exhibited poor resiliency and response to treatment (score 4). The records document that the patients depression, anxiety, and suicidal ideation continued even after inpatient hospitalization. He also continued to express suicidal ideation at the RTC. Previous treatment has not achieved complete remission of symptoms or optimal control of symptoms even with intensive and/or repeated exposure to treatment.For dimension 6, the patients parents have been incompletely engaged (score 3) since they actively participated in treatment, but the patients mother continues to struggle to accept the patients gender identity, which has contributed to the patients distress. The records document that the patients parents have been unable to participate consistently in treatment, with inconsistent follow-through.These findings give the patient a composite score of 21, which is consistent with medically monitored residence-based services. Furthermore, the patient qualifies for Level 5B intermediate stay medically monitored residence-based services since the patients Family has difficulty responding to childs needs appropriately. In this case, the patients parents have struggled to respond to his self-harm and suicidal ideation, and have struggled to accept patients gender identity, which has increased the patients distress. Per Russell and colleagues, this clinical setting places the patient at higher risk of suicidal ideation and suicidal behavior. The patient also experienced peer conflict shortly before his hospitalization. Per CALOCUS, the length of stay at Level 5B is up to 60 days. Thus, RTC services for 60 days after admission are supported as medically necessary. Additional time in RTC is appropriate to prevent suicidal behavior and to give the family more time to address conflict regarding the patients gender identity. Moreover, the 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, the psychiatric 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.