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

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement and prospective 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 RTC services. For dimension 1, the patient has been at serious risk of harm (score 4) due to indication or report of significant impulsivity and physical aggression, with poor judgment and insight, and that have been significantly endangering to self or others. The patient was aggressive at home and school prior to her admission and continued to be aggressive toward staff and a peer while at the RTC. She also engaged in self-harm. Also, the patients struggle with self-care, as demonstrated by her refusal to shower or brush her teeth for days, qualifies as a serious risk of harm per CALOCUS. For dimension 2, the patient has exhibited serious functional impairment (score 4) given her conflict with family members, peers, and RTC staff during residential treatment. The patients extreme withdrawal including refusal to leave her room except for food, lack of self-care not showering or brushing teeth for days, and suspension from school, followed by home hospital schooling, and multiple class failures during the pandemic, all demonstrate serious functional impairment. The patient has shown serious deterioration of interpersonal interactions with consistent conflict or otherwise disrupted interactions with others, which may include impulsive or abusive behaviors. For dimension 3, the has no comorbidities (score 1). The patient has no evidence of medical illness, substance abuse, developmental disability, or psychiatric disturbances apart from the presenting condition. Although an autism spectrum disorder was suspected, and testing was completed during treatment, and no diagnosis was given during the period under review. For dimension 4A, the patients recovery environment was mildly stressful (score 2) considering the disruptions caused by the pandemic, including social isolation during online school and the cancelation of dance practice. The patient has expectations for performance at home and school that create discomfort as demonstrated by her emotional dysregulation when told she is unable to do something, and her academic struggles in the spring, as well as the prior need for home hospital schooling. Significant transition requiring adjustment, such as isolation during quarantine. For dimension 4B, the patients recovery environment is supportive (score 2) due to parents participation in treatment and treatment planning. Family caretakers 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 moderate or equivocal resiliency and response to treatment (score 3). Previous experience in treatment at low level of intensity has not been successful in relief of symptoms or optimal control of symptoms. The patients symptoms continued to worsen after outpatient therapy and medication management. For dimension 6, the patient has been non-collaborative in treatment (score 4), due to her refusal to engage actively in treatment, as evidenced by her refusal to participation in family therapy or follow RTC staff instructions when dysregulated. She also blames her parents for being admitted to the RTC and struggles to accept responsibility for her behaviors. The patient accepts no age-appropriate responsibility role in development, perpetuation, or consequences of the problem. These findings give the patient a composite score of 20, which is consistent with medically monitored community-based services. Due to serious risk of self-harm and serious functional impairment, the patient qualifies for Level 5 medically monitored residence-based services. Furthermore, the patient qualifies for Level 5B intermediate stay medically monitored residence-based services, given the significant disturbance in interpersonal interactions with consistent conflict or otherwise disrupted interactions with others, which may include impulsive or abusive behaviors. Inability to perform adequately even in a specialized school setting due to disruptive behavior, or in attentiveness. In this case, the patient had a history of conflict and aggression at home and school and continued to engage in conflict and aggression at the RTC. She had also refused to attend online school in the spring and failed multiple classes. Per CALOCUS, the typical length of stay at Level 5B is up to 60 days. Based on the patients history and current symptoms, RTC services are medically necessary for 60 days from admission. Therefore, the RTC services were and are medically necessary for treatment of this patient.Final Result: The reviewer determined that the services at issue were and 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.