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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for residential treatment center (RTC) services. 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 significant risk of harm (score 3) due to self-injurious behaviors in the form of cutting and burning herself. She endorses passive suicidal ideation. She does not have a history of suicide attempts. She has also been engaging in dietary restriction alternating with binging and purging. She is using cannabis multiple times a day and drinking alcohol. The records also describe the patient as impulsive. The patient is in extreme distress as evidenced by her precipitous decline in functioning. No active suicidal or homicidal ideation, but extreme distress and a history of suicidal behavior. For dimension 2, the patient has demonstrated serious functional impairment (score 4) since she dropped out of school, barely leaves her room, has shown a decline in hygiene, and inadequate nutritional intake. The patient is not attending to multiple activities of daily living. This supports significant withdrawal and avoidance of almost all social interaction and consistent failure to achieve self-care/hygiene at levels appropriate to age and developmental level. For dimension 3, the patient has major comorbidities (score 4) considering her diagnoses of depression, anxiety, obesity, and nicotine dependence. The patient endorses twice daily use of cannabis and intermittent alcohol use. The patient is noted to have insomnia, which can also exacerbate depression and anxiety and in turn, can be exacerbated by depression and anxiety. Medical conditions are present that will adversely affect, or be adversely affected by, the presenting condition. For dimension 4A, the patients recovery environment is moderately stressful (score 3) as she does not have a good relationship with her mother, and her mother struggles with alcohol dependence. Her relationship with her family members is strained as they do not understand her mental health issues. She is unable to attend school or an intensive outpatient program due to due her agoraphobia and panic attacks. This supports disruption of family and social milieu. For dimension 4B, the patients recovery environment is minimally supportive (score 4) given the lack of a good relationship with her mother. Her father and brother, with whom she lives, reportedly do not understand her mental health issues. Family or other primary caretakers display limited ability to participate in treatment or service plan. For dimension 5, the patient has exhibited poor resiliency and response to treatment (score 4). The records document that the patient has shown poor response to treatment and recovery management. Previous treatment in outpatient was insufficient to manage patients symptoms and her condition deteriorated. She participated in an intensive outpatient program but stopped attending because of her agoraphobia. She has been treated with multiple medications without improvement on maximal doses or due to intolerance. The patients symptomatology has persisted despite multiple treatment attempts. 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 patient has been incompletely engaged in treatment (score 3) since she has struggled to engage in treatment, exhibiting low internal motivation. She has shown difficulty in attending groups or sessions without significant support and direction. Frequently misses or is late for treatment appointments and/or is not invested in treatment, including medication and homework assignments. 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 score of 4 for functional status also supports treatment at Level 5 medically monitored residence-based services. Moreover, the requested 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 requested RTC services are 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.