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 services for three months.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 suicidal ideation, with an attempt to jump out of window, and an overdose on risperidone, leading to two recent psychiatric hospitalizations. The patient's impulsivity and excessive daily substance use led to dangerous behaviors such as driving while intoxicated. The patients parent also reported aggressive behavior by the patient when his access to cannabis was denied. [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 note that the patient experienced a rapid decline in school attendance and academic achievement due to his substance use and mental health symptoms, which put the patient on track to fail multiple classes. [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 significant co-morbidity, due to the combination of substance use and mental health symptoms. [Score 3  Significant 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 the death of his father two years ago by overdose, and the disruptions caused by the COVID-19 pandemic. [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 is supportive, due to his parent's involvement in his care. [Score 2  Supportive 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 poor resiliency due to his continued struggles with substance use and mental health symptoms after two hospitalizations, partial hospital treatment, and two admissions to short-term residential treatment. [Score 4  Poor 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 constructively engaged due to his active participation in treatment and his motivation for treatment. [Score 2  Constructive Engagement]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 his recent heavy substance use that was temporarily arrested due to the use of a highly structured or protected setting. The patient had relapsed one week after his discharge from previous residential treatment, and he had not responded to previous short-term attempts at residential treatment. Per CALOCUS, the usual length of stay at Level 5B is up to 60 days. Therefore, the services at issue and requested services are medically necessary for up to 60 days. The patient does not currently qualify for long-term residential treatment, which would involves stays from two months up to one year, and approval of additional days of residential treatment would require another future review, with updated clinical information explaining the patients need for continued residential treatment beyond 60 days. Accordingly, residential treatment services are medically necessary for up to 60 days to treat the patients condition.Final Result: The reviewer determined that the services at issue and requested services were, and are, partially medically necessary to treat the patient's 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.