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

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement for residential treatment center services.The Child and Adolescent Level of Care Utilization System (CALOCUS) provides a 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 (Astressors, 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. In this case, CALOCUS scores are as follows:For dimension 1  Risk of Harm. This dimension assesses potential for harm to self or others, or having harm inflicted upon them. The records note that the patient had a history of impulsive aggression, anger outbursts, and threats of violence at home and at the residential treatment center. [Score 4  Serious Risk of Harm]For dimension 2  Functional Status. This dimension assesses the degree to which a person is able to fulfill responsibilities for a given age level. The records describe the patient as having serious functional impairment, as the patient had serious deterioration of interpersonal interactions with consistent conflict or otherwise disrupted interactions with others, which included impulsive or abusive behaviors. This was evidenced by both the patients and his parents' reports of conflict at home, as well as the patients struggles with peer conflict at the residential treatment center, and interactions with parents during family sessions. The patients symptoms were also affecting his academic performance. [Score 4  Serious Functional Impairment]For dimension 3  Comorbidity. This dimension assesses the co-existence of disorders across four domains (psychiatric, substance use, medical or developmental) that may complicate the course of treatment. The patient had minor co-morbidity, due to recent marijuana use. [Score 2  Minor Co-Morbidity]For Recovery Environment dimension 4A  Stress. This dimension assesses the stressors in the environment, social circumstances, and interpersonal relationships. The patients recovery environment was moderately stressful, due to role expectations that exceeded the patients capacity given his age, stage, and developmental level, as demonstrated by his parents' tendency to place academic pressure on him, and frequent arguments between the patient and his parents. [Score 3  Moderately Stressful Environment]For Recovery Environment dimension 4B  Support.  This dimension assesses the presence of family and social support to augment the recovery environment. The patients recovery environment appeared to have limited support. The patients family demonstrated only partial ability to make necessary changes during treatment, as evidenced by the patients mother becoming dysregulated during a family session and during conversations with a residential treatment center therapist. [Score 3  Limited Support in Environment] For dimension 5  Resiliency and Treatment History. This dimension assesses success or failure to make use of treatment and natural support that fosters resilience. The patient showed a moderate or equivocal resiliency and/or response to treatment, as he did not respond to one year of outpatient therapy and medication management. [Score 3  Moderate or Equivocal resiliency and/or Response to Treatment]For dimension 6  Treatment Acceptance and 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 was incompletely engaged, due to his difficulty accepting responsibility for his role in maintaining his difficulties and perpetuating conflicts at home and at the residential treatment center. [Score 3  Incompletely Engaged]These findings give the patient a composite CALOCUS score of 22, which is consistent with Level 4: Medically Monitored Community Based Services. The patients scores of 4 in the Risk of Harm and Functional Status dimensions, however, automatically qualify him for Level Five: Medically Monitored Residence-Based Services. Furthermore, the patient qualifies for Level 5B: Intermediate Stay Medically Monitored Residential Programs, due to significant disturbance in interpersonal interactions with consistent conflict or otherwise disrupted interactions with others, which may include impulsive or abusive behaviors, as evidenced by frequent conflict with his parents at home, and conflict with his peers at the residential treatment center. Per CALOCUS, the usual length of stay at Level 5B is up to 60 days. In this case, the length of stay was approximately 49 days, which is well within CALOCUS guidelines for this level of care. Accordingly, the residential treatment services at issue were medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the services at issue were medically necessary to treat 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.