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

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement 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 CALOCUS, this patient met the criteria for RTC services. For dimension 1, the patient was at serious risk of harm (score 4), due to indication or report of significant impulsivity with poor judgment and insight, and that were significantly endangering to self or others. In addition, the patients recent pattern of excessive substance use resulted in clearly harmful behaviors with no demonstrated ability of the patient or family to restrict use as evidenced by the patients recent episode of blacking out after taking Xanax and alcohol and recent suicide attempt. For dimension 2, the patient demonstrated moderate functional impairment (score 3) given her social withdrawal. Recent gains and stabilization in functioning were achieved while participating in treatment in a structured, protected, and/or enriched service as evidenced by decreasing suicidal ideation and improved functioning. For dimension 3, the patient has significant co-morbidity (score 3) considering her recent substance use that had significant impact on the presenting condition was arrested due to use of a highly structured or protected setting. The patient reportedly stopped using substances during her stay in the RTC. For dimension 4A, the patients recovery environment was mildly stressful (score 2) due to disruptions caused by the Covid-19 pandemic, and expectations for performance at home or school that create discomfort. The patient struggled with the rules and expectations at the RTC, and she was using substances to cope with depression and anxiety symptoms prior to admission to the RTC. For dimension 4B, the patients recovery environment was supportive (score 2) as his parents were active participants in her treatment. The patients family were willing and able to participate in treatment and had the capacity to effect needed changes. For dimension 5, the patient exhibited poor resiliency and response to treatment (score 4) as previous treatment has not achieved complete remission of symptoms or optimal control of symptoms even with intensive and/or repeated exposure to treatment. The records document that the patients depressive symptoms worsened and she continued to abuse substances despite multiple prior attempts at treatment at various levels of care. For dimension 6, the patient was constructive in treatment (score 2) due to her general cooperation with treatment. The patient passively cooperated with treatment planning and treatment. These findings give the patient a composite score of 20, which is consistent with medically monitored community-based services. Per CALOCUS, the patients score of 4 on risk of harm supports Level 5 medically monitored residence-based services. Furthermore, the patient qualified for Level 5B intermediate stay medically monitored residence-based programs since recent gains and/or stabilization in functioning have been achieved while participating in treatment in a highly structured, protected, and/or enriched service. Also, the patients substance use was temporarily arrested during her stay in RTC. Per CALOCUS, the length of stay at Level 5B usually does not exceed 60 days. In this case, the total stay in RTC was well within the recommended length of treatment based on the CALOCUS algorithm. For these reasons, the RTC services were medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were 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.