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

Nature of Statutory Criteria/Case Summary:The parent of an enrollee has requested reimbursement and authorization and coverage for residential treatment center (RTC) services.The Child and Adolescent Level of Care Utilization System (CALOCUS) provides a reliable 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 (a. stressors 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.For dimension 1- Risk of Harm. This dimension assesses potential for harm to self or others. The patient has a history of three suicide attempts/gestures as well as self-harming behaviors. She has also expressed homicidal ideation, with no specific plans in recent time. The patient also has poor self-esteem especially related to body image concerns. [Score 3  significant]For dimension 2  Functional Status. This dimension assesses the degree to which a person is able to fulfill social responsibilities, interacts with others, and maintains physical functioning and capacity for self-care. The patient has a history that includes school failure and avoidance, conflicts with her parents, self-harm, multiple depressive symptoms, drug use, suicide attempts, and running away behaviors. The patient exhibits poor impulse and frustration tolerance. The patient also has a history of eating disorder symptoms that are at risk of re-emerging. [Score 4  serious]For dimension 3  Comorbidity. This dimension assesses potential complications in the course of treatment due to acuity or disability related to co-occurring medical illness, substance use disorder, or psychiatric disorder. The patient has major co-morbidities that include bipolar affective disorder, anorexia nervosa restricting type, parent child relational problem, and significant substance use disorder. [Score 4  major]For Recovery Environment dimension 4A- Stress. This dimension assesses the stressors in the patients environment, social circumstances, and interpersonal relationships. The patient appears to have had a stressful environment involving very conflictual family dynamics. [Score 4  highly stressful]For Recovery Environment dimension 4B- Support. This dimension assesses the presence of family and social support to augment the patients recovery environment. The patients parents appear to have been unable to respond to the patients developmental needs and/or problems, and the patient has perceived that her family has been invalidating at times. [Score 3  limited support]For dimension 5- Treatment and Recovery History. This dimension assesses how past experiences with treatment and recovery might indicate how the patient might respond in the future. The patient appears to have a history of some response to residential treatment that she has previously received, as eating disorder symptoms and auditory verbal hallucinations improved, but she appears to require more extensive treatment than she has received given her ongoing suicidal ideation and severe parent child issues. The patients community level of care appears to have had limited effect. [Score 3- moderate or equivocal response]For dimension 6  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 has had challenges with family therapy and has verbalized an ongoing desire to relapse on drugs while currently at a residential level of care. The patient has struggled with utilizing skills to ground herself, she has frequently been emotionally fragile, and she is still noted to make demeaning comments about herself. [Score 3- incomplete engagement]These findings give the patient a composite CALOCUS score of 24, which is consistent with Level 5: Medically Monitored Residence-Based Services. The patients scores of 4 in Functional Status and Comorbidity dimensions also automatically qualify the patient for Level 5 services. Records reflect that the patient has struggled with suicidal ideation, eating disorder symptoms including distorted and poor body image, severe parent-child relational conflicts, self-harm, and drug use. The patients symptoms warrant residential treatment center level of care, given her fragile clinical presentation. While the patient has denied active suicidal ideation, homicidal ideation or auditory verbal hallucinations, she is at risk of decompensating back to active suicidal ideation, self-harm, and drug use if she is at a lower level of care, given her need for ongoing intensive individual, group, and milieu therapy, as well as medication management and structured routines. Accordingly, the requested residential treatment center (RTC) services were, and are, medically necessary for the patients medical condition.Final Result: The reviewer determined that the services at issue and requested services were, and are, medically necessary for 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.