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. Applying the CALOCUS framework, this patient met the criteria for RTC services. For dimension 1, the patient was at significant risk of harm (score 3) due to suicidal ideation for several years with thoughts of overdosing or slitting his wrists. The patient also has a history of anger and poor frustration tolerance, with significant self-loathing and guilt issues. No active suicidal ideation but extreme distress and a history of suicidal behavior. For dimension 2, the patient demonstrated serious functional impairment (score 4) given his history of self-injurious behaviors, suicidal ideation and inability to complete expectations such as attend school. There was evidence of withdrawal and inability to maintain relationships in the home. Significant withdrawal and avoidance of almost all social interaction. For dimension 3, the patient has major comorbidities (score 4) with a history of depression, anxiety, and parent-child relational problems. In addition, the patient has epilepsy, which is associated with a higher rate of depression. Medical condition were present that will adversely affect, or be affected by, the presenting condition. For dimension 4A, the patients recovery environment was highly stressful (score 4). The records document that the patients father has high expectations. The passing of the patients mother has impacted the patient tremendously. The patients father acknowledged difficult dynamics with the patient. Serious disruption of family or social milieu due to illness, death, divorce or separation of parent and patient. For dimension 4B, the patients recovery environment provided limited support (score 3). The provider noted that the patients family appears supportive, but it is a blended family with ongoing challenging dynamics. Family has limited ability to respond appropriately to patients developmental needs and problems or is ambivalent toward meeting these needs or addressing these problems. For dimension 5, the patient exhibited moderate or equivocal resiliency and response to treatment (score 3) considering his continued self-injurious behaviors and suicidal ideation despite treatment. The patient demonstrated withdrawal and inability to maintain relationships in the home. Developmental pressures and life changes have caused some deterioration in function. For dimension 6, the patient was constructive in treatment (score 2) since he attended group sessions as well as individual and family therapy. The patient experienced challenges with perspectives but he was fairly cooperative with treatment and trying to delve into concerns. Unable to define the problem but could understand and accept how others define the problem and its consequences. These findings give the patient a composite score of 23, which is consistent with medically monitored residence-based services. Per CALOCUS, the patients score on functional status supports treatment at Level 5,  medically monitored residence-based services. For these reasons, 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.