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 expressed suicidal ideation with intent and plan prior to hospitalization and subsequent RTC admission. The patient has also expressed active suicidal ideation during the RTC stay and noted that they would kill themselves after discharge. Current suicidal or homicidal ideation with either clear, expressed intentions and/or past history of carrying out such behavior. The patient has expressed ambivalence about carrying out the safety plan and their familys ability to carry out the safety plan is compromised. For dimension 2, the patient has demonstrated moderate functional impairment (score 3) given the patients conflict with parents and difficulty getting along with peers. The RTC staff noted that the patient was performative and dishonest. The patient reported doing well in school and showed some improvement in the structured setting of the RTC. Conflicted, withdrawn, or otherwise troubled in relationships with peers, adults and family, but without episodes of aggression. For dimension 3, the patient does not have any reported comorbidities (score 1). The records do not document any substance abuse, medical, or developmental disorders. There is no evidence of medical illness, substance abuse, developmental disability, or psychiatric disturbances apart from the presenting condition. For dimension 4A, the patients recovery environment has been highly stressful (score 4). The provider noted that there are high levels of parental conflict and they are planning to divorce. This supports serious disruption of family or social milieu. For dimension 4B, the patients recovery environment has provided limited support (score 3) considering her parents difficulty in managing the patients symptoms and behaviors at home. Family or primary caretakers demonstrate only partial ability to make necessary changes during treatment. For dimension 5, the patient has exhibited poor resiliency and response to treatment (score 4) since the patient has continued to report suicidal ideation. The patient has struggled with emotional and behavioral dysregulation despite outpatient treatment, IOP, DBT, and an inpatient hospitalization. Previous treatment has not achieved complete remission of symptoms or optimal control of symptoms even with intensive and repeated exposure to treatment. For dimension 6, the patient has been incompletely engaged in treatment (score 3) considering their inconsistent cooperation with treatment. Ambivalent, avoidant, or distrustful relationship with clinicians and other care providers. These findings give the patient a composite score of 22, which is consistent with Level 5 medically monitored residence-based services. Furthermore, the patient qualifies for Level 5B intermediate stay medically monitored residence-based services since Previous treatment, particularly in less intensive levels of care, has not been successful, and child has developed limited resilience, as demonstrated by the patients continued symptoms after years of outpatient treatment, DBT, IOP, and an inpatient hospitalization. Per CALOCUS, the length of stay at Level 5B usually does not exceed 60 days, which is consistent with this patients treatment plan. Moreover, the RTC services are in accordance with the generally accepted standards of mental health and substance use disorder care, clinically appropriate in terms of type, frequency, extent, site, and duration, and not primarily for convenience of the patient or provider. All told, 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.