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 structured 90-day residential treatment center (RTC) program, or in the alternative, 75 days of RTC services. 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 meets the criteria for a structured 90-day RTC program.For dimension 1, the patient has been at serious risk of harm (score 4) due to use of multiple substances and alcohol, as well as a history of overdose on opioids several times in the past. The patient has not demonstrated any ability to restrict his substance use and the records suggest that his parents have not been successful in restricting his access to substances as demonstrated by his continued use. The patient describes himself as impulsive and he reports that he enjoys engaging in dangerous behaviors. Current suicidal or homicidal ideation with either clear, expressed intentions and past history of carrying out such behavior. The patient has expressed ambivalence about carrying out the safety plan and his familys ability to carry out the safety plan is compromised. There is also indication or report of significant impulsivity, with poor judgment and insight, and that are significantly endangering to self or others. Moreover, the records support a recent pattern of excessive substance use resulting in clearly harmful behaviors with no demonstrated ability of the patient or family to restrict use. For dimension 2, the patient has demonstrated serious functional impairment (score 4) given his difficulty in the school setting and decline of grades due to his substance use. The provider noted that the patient has been suspended multiple times for drug related activity and he was expelled from school for being under the influence of drugs. The patient also struggles to manage his emotions. Inability to perform adequately even in a specialized school setting due to disruptive behavior, or inattentiveness. School attendance may be sporadic. The patient has multiple academic failures. For dimension 3, the patient has major comorbidities (score 4) considering his diagnoses of depression and anxiety, as well as polysubstance use disorders. The patient reported using cannabis, alcohol, and fentanyl on a daily basis prior to admission. When asked about coping skills, patient identifies drugs as his coping skill. Uncontrolled substance use is present that poses a serious threat to health if unabated and impedes recovery from the presenting condition. For dimension 4A, the patients recovery environment is highly stressful (score 4) as several family members also struggle with mental health issues and his parents are noted to frequently argue. There is also conflict between the patient and his parents because of his substance use. The patient also appears to have difficulty avoiding exposure to substance use as he uses substances daily. This supports a serious disruption of family and social milieu. For dimension 4B, the patients recovery environment appears to be supportive (score 2) as evidenced by the patients report that his family is happy that he is in treatment. However, the patient also indicated that his parents do not talk openly about important subjects, which suggests that meaningful communication is lacking or limited. His parents have been engaged in family sessions but have struggled to understand the patients emotional experience. 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 the patient was previously engaged in outpatient therapy and medication management, but he has been unable to achieve or maintain sobriety. He has also shown poor resiliency as evidenced by his continued use of substances in response to life stressors and as a means of coping with his anxiety. Child has demonstrated frequent evidence of innate vulnerability under stress and difficulty resuming progress toward expected developmental level. For dimension 6, the patient has been incompletely engaged in treatment (score 3) as evidenced by reports that he appears to be holding back and lacking insight or ability to discuss his family issues. Ambivalent, avoidant, or distrustful relationship with clinicians and other care providers. These findings give the patient a composite score of 25, which is consistent with Level 5 medically monitored residence based-services. Per CALOCUS, the patients scores of 4 for risk of harm, functional status, and comorbidity also support treatment at Level 5 medically monitored residence-based services level of care. Moreover, the patient meets the criteria for Level 5C long-term medically monitored residence-based services due to the presence of uncontrolled substance use is present that poses a serious threat to health if unabated and impedes recovery from the presenting condition. Furthermore, 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. For these reasons, a structured 90-day RTC program 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.