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

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for treatment plan including: close monitoring and follow-up with a child and adolescent psychiatrist; parent coaching; family therapy; individual trauma focused cognitive therapy; and in-person occupational therapy, and the treatment plan including: trauma-informed mental health services by a qualified provider; individual trauma-based therapy; and parental involvement: family therapy or collateral services, at a minimum frequency of 60 minutes a week. 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 meets the criteria for the treatment plan.For dimension 1, the patient has been at serious risk of harm (score 4) due to his history of headbanging and punching wall when dysregulated. The patient also has a history of aggression towards others and he has caused bruises and scratch marks on his mother. He has threatened to kill his parents, physically harm his peers, and he has issues with elopement. He has a history of suicidal ideation with thoughts of throwing himself off of a building but no expressed intent. Indication or report of significant impulsivity and physical aggression, with poor judgment and insight, that are significantly endangering to others.For dimension 2, the patient has demonstrated serious functional impairment (score 4) given his inability to pass second grade, difficulty sleeping in his own bed, and difficulty with friendships due to his abusive and acting out behaviors. In addition, the patient has severe deficits in interpersonal relationships with his parents and he engages in assaultive behaviors with little or no provocation. Significant deterioration of interpersonal interactions with consistent conflict or otherwise disrupted interactions with others, which may include impulsive or abusive behaviors.For dimension 3, the patient has significant comorbidities (score 3) considering his sensory hypersensitivity issues suggestive of a developmental disability, which would play a significant role in his emotional and behavioral reactivity as well as hypervigilance. He also has beendiagnosed with a specific learning disability. For dimension 4A, the patients recovery environment has been moderately stressful (score 3). The records document that the patients current stressful circumstances include social isolation due to COVID-19 and cancellation of in-person school and engagement in vigorous physical activity. This supports a disruption of family and social milieu.For dimension 4B, the patient has limited support in his recovery environment (score 3) since the provider noted that his parents appear to be supportive and willing to engage as evidenced by documentation from crisis team. However, current community resources appear to be inadequate to meet this patients emotional needs. Family has limited ability to respond appropriately to the patients developmental needs and problems or is ambivalent toward meeting these needs to addressing these problems.For dimension 5, the patient has exhibited moderate to equivocal resiliency and response to treatment (score 3) as previous outpatient treatment has not ameliorated symptoms and appears to be lacking in frequency. Previous experience in treatment at low level of intensity has not been successful in relief of symptoms or optimal control of symptoms.For dimension 6, the patient has been incompletely engaged in treatment (score 3). The provider noted that the patient was able to answer questions when speaking to his provider and he expressed a willingness to enter a treatment program. The patient acknowledges the existence of a problem, but resists accepting even limited age-appropriate responsibility for development, perpetuation, or consequences of the problem.These findings give the patient a composite score of 23, which is consistent with medically monitored residence-based services. Per CALOCUS, the patients scores of 4 on risk of harm and functional status also meet the criteria for Level 5 medically monitored residence-based services. The requested services are consistent with Level 4 medically monitored community-based services, which includes clinical services which are available at times that meet the needs of the family, including non-traditional periods. In addition, the records support trauma-based psychotherapy as a first-line treatment for children and adolescents with PTSD and is consistent with the recommendations from the AACAP. The requested parent management training in the use of contingency management methods to help them better handle disruptive behavior and family therapy are also supported by the AACAP for the treatment of patients with oppositional defiant disorder. Furthermore, trauma focused CBT is an empirically supported intervention advocated by the AACAP. The AACAP supports the recommendation for trauma focused cognitive therapy and the recommendation for trauma-informed mental health services by a qualified provider.Given this support, the requested treatment plan is medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested services 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.