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

Nature of Statutory Criteria/Case Summary: The patient 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 the CALOCUS guideline, this patient met the criteria for RTC services. The records document that the patient was at serious risk of harm (score 4) due to her aggressive behaviors, impulsivity, running away, substance use, and involvement with older men, which placed her at risk of victimization. The patient demonstrated moderate functional impairment (score 3) given her family conflict and refusal to attend school. The patient has significant comorbidities (score 3) considering her substance abuse as well as post-traumatic stress disorder (PTSD), anxiety, and a learning disability. The patients recovery environment was moderately stressful (score 3) as the records noted she has a history of sexual assault and threat of victimization by older men. The patients recovery environment was supportive (score 2) as her parents attempted to connect with the patient during treatment. The patient has exhibited poor response to treatment (score 4). The provider noted that the patients condition failed to improve with outpatient and RTC levels of care. The patient was incompletely engaged in treatment (score 3) due to her denial for her need for treatment and minimization of her problem behaviors. This gives the patient a composite score of 22, which is consistent with medically monitored community based services. However, due to the patients score of 4 on risk of harm, she met the criteria for Level 5 medically monitored residence based services. Furthermore, the patient met the criteria for Level 5B intermediate stay medically monitored residence based services based on her impulsivity, level of distress, comorbidities, and lack of response to outpatient care, as well as her ambivalence toward making changes in treatment. Per CALOCUS, a Level 5B length of stay usually does not exceed 60 days. Based on these findings, the first 60 days of treatment were medically necessary for this patient, at which time the patient could have been stepped down to a lower level of care. Thus, a portion of the RTC services was medically necessary for treatment of this patient. Final Result: The reviewer determined that a portion of the services at issue was medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially 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.