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

Nature of Statutory Criteria/Case Summary: The patients parent 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 indication or report or incidents of acting without thinking and physically aggressive actions that endangered self and others, as demonstrated by her physical aggression toward her mother. The patient demonstrated periods of inability to care for self and maintain physical safety in developmentally appropriate ways. Per her mothers report, the patient was not consistent in taking her medications and had deficits in personal hygiene. For dimension 2, the patient exhibited serious functional impairment (score 4) given her serious deterioration of interpersonal interactions with consistent conflict or otherwise disrupted interaction with others, which included impulsive and abusive behaviors. This was evidenced by the patients altercations with her mother involving physical aggression. The patient also showed a consistent failure to achieve self-care/hygiene at levels appropriate to age and/or developmental level. The patient and her mother reported that the patient struggled with hygiene and self-care. For dimension 3, the patient has significant comorbidities (score 3). The provider noted that the patient lacks a spleen, which leads to an immunocompromised state. Also, she was diagnosed with an autism spectrum disorder, which is a developmental disability that affects her interactions with others. Developmental disability is present that adversely affected the presenting condition and/or required significant augmentation or alteration of treatment for the presenting condition or comorbid condition, or adversely affected the presenting condition. In addition, medical conditions are present requiring significant medical monitoring. For dimension 4A, the patients recovery environment was mildly stressful (score 2) given the disruptions to school, social and leisure activities caused by the pandemic, as well as conflicts with parents, and parents conflicts with each other. This supports significant transition requiring adjustment, such as change in household members, or new school or teacher. For dimension 4B, the patients recovery environment was supportive (score 2) considering her parents active participation in treatment. Family caretakers were willing and able to participate in treatment if requested to do so and had capacity to effect needed changes. For dimension 5, the patient has demonstrated moderate or equivocal resiliency and response to treatment (score 3). Previous experience in treatment at low level of intensity has not been successful in relief of symptoms or optimal control of symptoms. The patient did not improve after several attempts at outpatient psychotherapy and she was refusing to see a therapist. For dimension 6, the patient was incompletely engaged (score 3) due to her minimization of her need for treatment at the RTC and difficulty accepting responsibility for her role in family conflicts. The patient minimized and rationalized distressing and consequences. These findings give the patient a composite score of 20, which is consistent with medically monitored community-based services. Per CALOCUS, the patients scores on functional status and scores on recovery environment, the patient met the criteria for Level 5, medically monitored residence-based services. Furthermore, the patient qualified for Level 5B, intermediate stay medically monitored residence-based services, due to significant disturbance in interpersonal interactions with consistent conflict or otherwise disrupted interactions with others, which may include impulsive or abusive behaviors. This is evidenced by the patients conflict with her mother. Per CALOCUS, treatment at Level 5B usually does not exceed 60 days. In this case, the patient participated in 45 days of RTC, which is within the CALOCUS guidelines. Therefore, the RTC services were medically necessary for 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.