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

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement for residential treatment center services.The Child and Adolescent Level of Care Utilization System (CALOCUS) provides a reliable framework for determining the clinically appropriate level of care for a child or adolescent in 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) resiliency and treatment history; and (6) treatment acceptance and engagement. The composite score is then used to determine the level of care needed.For dimension 1- Risk of Harm. This dimension assesses potential for harm to self or others. The patient had serious risk of harm, due to significant impulsivity with poor judgment and insight, that were significantly endangering to herself or others. This was demonstrated by the patient's multiple recent suicide attempts by overdose that required intensive care unit stays, her reports of persistent suicidal ideation, and risky behavior such as having repeatedly been AWOL from the residential treatment center. [Score 4  serious]For dimension 2  Function. This dimension assesses the degree to which a person is able to fulfill social responsibilities, interacts with others, and maintains physical functioning and capacity for self-care. The patient had moderate functional impairment, due to conflict with her parents and struggles with completing daily activities, including remote school. [Score 3  moderate]For dimension 3  Comorbidity. This dimension assesses potential complications in the course of treatment due to acuity or disability related to co-occurring medical illness, substance use disorder, or psychiatric disorder. The patient had no co-morbidity, due to the absence of substance abuse, medical problems, or developmental disorders. [Score 1- no co-morbidity]For Recovery Environment dimension 4A- Stress. This dimension assesses the stressors in the patients environment, social circumstances, and interpersonal relationships. The patients recovery environment was mildly stressful, due to disruptions to social life, school, and extracurricular activities caused by the pandemic, as well as conflict with parents. [Score 2 -mild]For Recovery Environment dimension 4B- Support. This dimension assesses the presence of family and social support to augment the patients recovery environment. The patient had a supportive environment, due to her parents' active participation in treatment and treatment planning. [Score 2- supportive]For dimension 5- Treatment and Recovery History. This dimension assesses how past experiences with treatment and recovery might indicate how the patient might respond in the future. The patient had poor resiliency and/or response to treatment, as demonstrated by the persistence of symptoms, including suicidality, after multiple psychiatric hospitalizations, participation in partial hospitalization programs and intensive outpatient programs, and outpatient therapy and medication management. [Score 4- poor response]For dimension 6  Engagement. This dimension assesses a persons understanding of their illness and treatment, and their ability and willingness to engage in the treatment process. The patient had incomplete engagement, as demonstrated by her instances of being AWOL from the facility, her inconsistent participation in treatment at the residential treatment center, and her tendency to blame others for her symptoms. [Score 3- incomplete engagement]These findings give the patient a composite CALOCUS score of 19. Due to the patients serious risk of harm, however, the patients recommended level of care is Level 5: Medically Monitored Residence-Based Services. Furthermore, the patient qualifies for Level 5B: Intermediate Stay Medically Monitored Residential Programs for two reasons. First, the patient experienced some suicidal ideation with some ambivalence and had a history of harm to herself. Impulsivity was also present and the risk of engaging in destructive behaviors was significant in an unstructured environment. This was demonstrated by the patient's poor insight and judgment at the residential treatment center and her multiple recent serious suicide attempts. Second, the patient was ambivalent and took limited responsibility for the change process. She was distrustful of clinicians and minimized the magnitude of her distressing behaviors and their consequences. This was demonstrated by the patients multiple AWOL attempts while at the facility, her inconsistent participation in treatment, and her eagerness to be discharged. Per CALOCUS, the length of stay at Level 5B is up to 60 days. In this case, the patients total stay at the residential treatment center was less than 30 days. Accordingly, the residential treatment center services at issue were medically necessary for the patients condition.Final Result: The reviewer determined that the services at issue were medically necessary for the patient's 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.