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 at least 90 days of residential treatment center (RTC) level of care in a secured facility, that specializes in treating adolescent females ranging from 12-17 years old, offers evidence-based medical and clinical treatment modalities such as cognitive behavioral therapy (CBT), dialectical behavioral therapy (DBT), Equine Assisted Growth and Learning Association (EAGALA) therapy, eye movement desensitization and reprocessing (EMDR), and medication management. 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 at least 90 days of RTC services. For dimension 1, the patient has been at serious risk of harm (score 4) due to report of significant impulsivity and physical aggression, with poor judgment and insight, and that are significantly endangering to self or others. This is evidenced by the patients recent impulsive attempts to climb onto the roof of the RTC, as well as recent attempts at self-harm while at the RTC. For dimension 2, the patient has demonstrated moderate functional impairment (score 3) given her conflicted, withdrawn, or otherwise troubled in relationships with peers, adults, and family, but without episodes of physical aggression. In addition, the provider noted that the patient has made some recent gains with her admitting symptoms, recognizing triggers, thoughts and emotions. The patient achieved recent gains in functioning while participating in treatment in a structured, protected, and enriched service. For dimension 3, the patient has no comorbidities (score 1). There is no evidence of medical illness, substance abuse, developmental disability, or psychiatric disturbances apart from the presenting condition. For dimension 4A, the patients recovery environment is moderately stressful (score 3) considering her recent loss of grandfather, parent-child relational issues, and inability to adequately perform in school. The records support an interpersonal or material loss has significant impact on child and family. For dimension 4B, the patients recovery environment is supportive (score 2) given her parents active participation in treatment. The patients family is 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 negligible resiliency and response to treatment (score 5). The patients past response to treatment has been minimal, even when treated at high levels of care for extended times. Her symptoms are persistent and her functional ability shows no significant improvement despite intensive treatment exposure. Previous treatment has not achieved complete remission of symptoms or optimal control of symptoms even with intensive and repeated exposures to treatment. For dimension 6, the patient has been incompletely engaged in treatment (score 3). The records document that the patient demonstrated an ambivalent, avoidant, and distrustful relationship with her clinicians and other care providers. Moreover, the patient minimizes and rationalizes her distressing behaviors and consequences. This gives the patient a composite score of 21, which is consistent with medically monitored community based services such as PHP. Per CALOCUS, the recommended level of care is Level 5, medically monitored residence-based services, due to the patients score of 4 on risk of harm. In addition, the patient qualifies for Level 5C long-term medically monitored residence-based program, due to minimal past response to treatment and inability to maintain any gains achieved outside an intensive and highly structured setting. Furthermore, the patients symptoms have been persistent despite extensive and intensive treatment exposure. Per CALOCUS, this type of RTC has the capacity to treat adolescents with long-term and persistent disabilities that require extended rehabilitation and skill building in order to develop capacity for community living. These facilities will provide intensive treatment as described for all Level 5 programs and the length of stay will vary from two months to a year. In this case, the patients longstanding suicidality and impulsivity place her at high risk, as demonstrated by her attempt to climb onto the roof of her RTC. Her providers have recommended long-term RTC services. For her safety, a secure facility is appropriate. Given these findings, at least 90 days of RTC level of care in a secured facility that specializes in treating adolescent females ranging from 12-17 years old, offers evidence-based medical and clinical treatment modalities such as CBT, DBT, EAGALA therapy, EMDR, and medication management is medically necessary for 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.