Appeal type: Medical Necessity
Decision: Overturned 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. 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. Based on the CALOCUS framework, this patient meets the criteria for RTC services. For dimension 1, the patient has been at serious risk of harm (score 4), due to recent pattern of excessive substance use resulting in clearly harmful behaviors with no demonstrated ability of the patient or family to restrict use. In this case, the patient had completed detoxification twice, experienced withdrawal symptoms at the RTC, and has lost significant weight due to his substance use. He also reported past suicidality. For dimension 2, the patient has demonstrated moderate functional impairment (score 3) given the effects of his depression and substance use on his performance in school, interpersonal relationships, and self-care. Conflicted, withdrawn, or otherwise troubled in relationships with peers, adults, and/or family, but without episodes of physical aggression. In addition, the patients self-care/hygiene deteriorates below usual or expected standards on a frequent basis and there are significant disturbances in physical function that do not pose a serious threat to health. Moreover, the patients school behavior has deteriorated to the point of the child/adolescent has faced some school disciplinary action and is at risk for placement in an alternative school program. For dimension 3, the patient has significant comorbidities (score 3) considering his past substance abuse which stopped in the protected setting of the RTC. Recent substance use that has significant impact on the presenting condition has been arrested due to use of a highly structured or protected setting or through other external means. For dimension 4A, the patients recovery environment has been moderately stressful (score 3), due to reported parental conflict, past bullying, and parental struggles to support the patients expression of his emotions during family therapy. This supports disruption of family and social milieu. For dimension 4B, the patients recovery environment has been supportive (score 2) since both of the patients parents have been actively involved in treatment and treatment planning. Family caretakers are willing and able to participate in treatment if requested to do so and have capacity to effect needed changes. For dimension 5, the patient has exhibited poor resiliency and response to treatment (score 4). The records document that previous treatment has not achieved complete remission of symptoms or optimal control of symptoms even with intensive and/or repeated exposure to treatment. In this case, the patient underwent two prior courses of detoxification and a prior stay in RTC, but his symptoms have persisted. For dimension 6, the patient has been constructive in treatment (score 2) due to his active participation in treatment at the RTC. Able to develop a trusting, positive relationship with clinicians and other care providers. These findings give the patient a composite score of 21, which is consistent with medically monitored community-based services. However, per CALOCUS, the patients score for risk of harm supports treatment at Level 5 medically monitored residence-based services. Furthermore, the patient qualifies for Level 5B intermediate stay medically monitored residence-based services, since substance use has been temporarily arrested due to use of a highly structured or protected setting. The patient has expressed concern that he would not be able to maintain sobriety at home. Per CALOCUS, the length of stay at Level 5B usually does not exceed 60 days. Thus, RTC services for 60 days are medically necessary for this patient. Moreover, the 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. Therefore, the RTC services were and are medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were and 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.