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 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 meets the criteria for 30 additional days of RTC services. For dimension 1, the patient is at serious risk of harm (score 4) due to significant impulsivity and physical aggression, with poor judgment and insight, and that are significantly endangering to self and others. This is demonstrated by the patients recent behaviors at the RTC, including kicking doors, punching windows, banging his head, and attempts to self-harm. The patient has also reported recent suicidal ideation to staff at RTC and has a history of acting on suicidal thoughts. For dimension 2, the patient has demonstrated serious functional impairment (score 4) given the serious deterioration of interpersonal interactions with consistent conflict or otherwise disrupted interactions with others, which may include impulsive or abusive behaviors. This is evidenced by the patients inappropriate conversations with peers. The patients parents also noted difficulty managing the patients behavior prior to RTC admission. For dimension 3, the patient has significant comorbidities (score 3) considering the recent substance use that has significant impact on the presenting condition that has been arrested due to use of a highly structured or protected setting or through other external means. The patient has a history of polysubstance abuse. The patient relapsed in April 2020 but has been sober in the context of RTC since May 2020. For dimension 4A, the patients recovery environment is mildly stressful (score 2). The records document that the patient has ongoing conflict with his parents. There are expectations for performance at home or school that create discomfort.For dimension 4B, the patients recovery environment is supportive (score 2) due to his parents participation in treatment and treatment planning. The patients family 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) since previous treatment has not achieved complete remission of symptoms or optimal control of symptoms even with intensive and repeated exposure to treatment. The patient has reportedly continued to struggle with self-harm, impulsivity, aggression, emotion regulation, and interpersonal relationships despite multiple inpatient hospitalizations, prior RTC treatment, and various other levels of care. For dimension 6, the patient has been incompletely engaged in treatment (score 3) as demonstrated by the patients minimization of his distressing behaviors and consequences. The provider noted that the patient refuses to engage with staff during episodes of self-harm. These findings give the patient a composite score of 22, which is consistent with medically monitored community based services. Due to the patients scores of 4 for risk of harm and functional impairment, the patient qualifies for Level 5 medically monitored residence-based services. Furthermore, the patient qualifies for Level 5C long-term medically monitored residence-based services given his minimal past response to treatment and inability to maintain any gains achieved outside an intensive and highly structured setting. Per CALOCUS, at Level 5C, the length of stay will vary from two months to a year. With a projected discharge of October 2020, patients stay at the current RTC would be less than five months. Therefore, the requested RTC services are 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.