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

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement and authorization and coverage for residential treatment center level of care.  Findings:  The physician reviewer found that 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 significant risk of harm, due to a history of severe physical and verbal aggression towards others as well as threats to harm himself when escalated. [Score 3  significant]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 had serious functional impairment, due to a history of highly disruptive behaviors and poor judgement with poor ability for adequate and safe functioning within the family. [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 had major co-morbidities  including attention deficit hyperactivity disorder (ADHD), oppositional defiant disorder (ODD), reactive attachment disorder (RAD), persistent depressive disorder with pure dysthymic syndrome, and mild unspecified anxiety disorder. [Score 4- major co-morbidity]For Recovery Environment dimension 4A- Stress. This dimension assesses the stressors in the patients environment, social circumstances, and interpersonal relationships. The patient appears to have had a highly stressful environment involving conflicts with his adoptive father and witnessing conflicts between family members. The patients adoptive mother also had brain surgery, thus contributing towards stress. [Score 4 highly 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 to have been at a loss as to how to parent the patient and were overwhelmed. The patient also had multiple severe conflicts with his father. [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 had poor resiliency as he had a history of limited response to outpatient therapy and continued to decompensate while at home. [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 had a history of poor insight and ongoing behavioral issues while at the residential treatment center as well as prior to the residential treatment center. While there was some improvement, the patient still required safety interventions and assessments up until very recently. [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 Functional Status and Co-Morbidity dimensions also automatically qualify the patient for Level 5 services. The patient has consistently demonstrated multiple lagging skills in the social and emotional realms with an inability to function safely outside of a highly structured setting, and residential treatment center level of care was, and is, appropriate. Accordingly, residential treatment center level of care provided from 2/28/20 and forward was, and is, medically necessary for the patients medical condition.Final Result: The reviewer determined that the services at issue and requested services were, and are, medically necessary for the patient's 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.