Appeal type: Medical Necessity
Decision: Upheld 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. Applying the CALOCUS framework, this patient does not meet the criteria for RTC services. For dimension 1, the patient has been at significant risk of harm (score 3) due to reports of suicidal ideation up to 8/10 intensity while in treatment and over the past few months, although no specific plans. The patient has multiple stressors and perfectionistic tendencies. By the date of denial, the patients suicidal ideation appeared to have resolved. No active suicidal ideation, but extreme distress and a history of suicidal behavior. For dimension 2, the patient has demonstrated moderate functional impairment (score 3) given the patients challenges with opening up and talking about codependency tendencies as well as dishonesty. The patient has continued to show difficulties communicating with her parents without therapist assistance. Conflicted, withdrawn, or otherwise troubled in relationships with family but without episodes of physical aggression. For dimension 3, the patient has minor comorbidities (score 2) with diagnoses of major depressive disorder, generalized anxiety disorder, and obsessive compulsive disorder. The patient also appeared to have concerns for an unspecified eating disorder issues and parent-child relational problems. The patient reported that she engaged in alcohol use in the month prior to treatment. Occasional, self-limited episodes of substance use are present that show no pattern of escalation, with no indication of adverse effect on functioning or the presenting condition. For dimension 4A, the patients recovery environment has been highly stressful (score 4). The provider noted that the patient has a history of significant  parent-child relational issues that contributed towards the patients symptoms of depression and anxiety. The patient also has a history of trauma with a friend. This support serious disruption of family milieu due to severe conflict. For dimension 4B, the patients recovery environment provided limited support (score 3) since her parents are well intentioned and have been working on trying to be more supportive. The patients sister is also making efforts to be supportive of the patient. Family has limited ability to respond appropriately to the patients developmental needs or problems or is ambivalent toward meeting these needs or addressing these problems. For dimension 5, the patient has exhibited moderate or equivocal resiliency and response to treatment (score 3). The records document that prior to RTC, the patient did not respond substantially to interventions. The patient did show some positive response to RTC level of care. 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 constructive in treatment (score 2) due to her hesitancy to initially participate in treatment, with gradual acceptance and engagement. Able to develop a trusting, positive relationship with clinicians and other care providers. These findings give the patient a composite score of 20, which is consistent with Level 4 medically monitored community-based services. By the date of denial, there were no issues with aggression, suicidality, unmanageable self-harm or other safety concerns. The RTC services were not and are not in accordance with the generally accepted standards of mental health care, or clinically appropriate in terms of type, frequency, extent, site, and duration. Therefore, the RTC services were not and are not medically necessary for treatment of this patient as defined by Health and Safety code section 1374.72 (a)(3)(A).Final Result: The reviewer determined that the services at issue were not and are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. 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 condi