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

The parent of an enrollee has requested reimbursement and authorization and coverage for six months of residential treatment center services in a secure facility.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 a history of significant physical and verbal aggression towards others as well as history of suicide attempts by overdosing and cutting. The patient has also engaged in risky behaviors through significant drug use and frequent elopement. [Score 4  serious]For dimension 2  Functional Status. 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 has a history of school failure, conflicts with parents, threats of self-harm, assault towards others, false allegations, multiple depressive symptoms, acts of self-harm, suicide attempts and threats, and running away behaviors. The patient has also exhibited extremely poor impulse/frustration tolerance. [Score 4  serious]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 has major co-morbidities that include major depressive disorder, generalized anxiety disorder, parent-child relational problem, and severe substance use disorder as well as a history of eating disorder. [Score 4  major]For Recovery Environment dimension 4A- Stress. This dimension assesses the stressors in the patients environment, social circumstances, and interpersonal relationships. The patient appeared to have had a moderately stressful environment involving conflictual family dynamics. [Score 3  moderately stressful]For Recovery Environment dimension 4B- Support. This dimension assesses the presence of family and social support to augment the patients recovery environment. The patients parents appear unable to contain the patient given her defiance and rule breaking, and they appear overwhelmed by the patients problems. [Score 3  limited support]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 appears to have a history of poor response to outpatient therapy with an inability to maintain safety within the home or community. The patient has demonstrated out-of-control risky behaviors including stealing her mothers van, running away multiple times, rampant drug and alcohol use, and general behaviors putting herself at risk of harm. [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. This was demonstrated by the patients limited improvement in behaviors and insight despite outpatient therapy and medication management. [Score 3- incomplete engagement]These findings give the patient a composite CALOCUS score of 25, which is consistent with Level 5: Medically Monitored Residence-Based Services. The patients scores of 4 in Risk of Harm and Functional Status dimensions also automatically qualify the patient for Level 5 services. Records reflect that the patient has consistently demonstrated severe functional compromise with an inability to maintain safety outside of a highly structured setting given rampant drug use, running away, stealing, lying, and assaultive behaviors, not to mention suicidal threats and attempts. The patient requires a locked, secure residential treatment facility given these extremely high-risk behaviors outside of a structured setting. Accordingly, the requested six months of residential treatment center services in a secure facility is medically necessary to treat the patients condition.