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

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) services for a 90-day program. 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 does not meet the criteria for RTC services. For dimension 1, the patient has been at significant risk of harm (score 3) due to reports of suicidal ideation with thoughts of overdosing and self-harming with a serrated edge of a tape dispenser. She has no prior suicide attempts or history of self-harm behaviors. Significant current suicidal ideation with some intent and plan, with an ability for the patient and her family to contract for safety or carry out a safety plan. The patient has expressed some reason not to carry out such behavior. For dimension 2, the patient has demonstrated moderate functional impairment (score 3), given her inability to continue in school because of inability to focus and lack of energy to complete schoolwork. School behavior has deteriorated to the point that the patient faces some school disciplinary action and is at risk for placement in an alternative school program. For dimension 3, the patient has minor comorbidities (score 2) with a diagnosis of asthma, for which she requires treatment with an inhaler. Self-limited medical conditions are present that are not immediately threatening or debilitating and that have no impact on the presenting condition and are not affected by it. For dimension 4A, the patients recovery environment has been moderately stressful (score 3) since the patients mother is noted to have depression and the patient is struggling in school. The patient is noted to have a good relationship with her parents and sibling. This supports disruption of family and social milieu. For dimension 4B, the patients recovery environment has been supportive (score 2). The provider noted that the patient reached out to her parents and informed them that she needed more intensive treatment beyond outpatient therapy. The patient continues to describe her relationship with her mother as superficial, and she states that she does not connect with her father. The patient also reported having two friends who are supportive. 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 exhibited moderate or equivocal resiliency and response to treatment (score 3) since previous experience in treatment at low level of intensity was not successful in relief of the patients symptoms. Her treatment history is less than one year and was limited to outpatient therapy. Previous experience in treatment at low level of intensity was not successful in relief of symptoms or optimal control of symptoms. For dimension 6, the patient has been constructive in treatment (score 2). The records document that the patient sought help through her parents. The provider has described the patient as motivated to improve her depressive symptoms. The patient has attended groups and participated in her therapeutic milieu. Able to develop a trusting, positive relationship with clinicians and other care providers. These findings give the patient a composite score of 18, which is consistent with high intensity community-based services. Moreover, the RTC services are not clinically appropriate in terms of type, frequency, extent, site, and duration. For these reasons, the psychiatric RTC services for a 90-day program were not and are not medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were not and are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. 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.