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

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for residential treatment center (RTC) services at a facility that specializes in children with autism and provides crisis residential level of care with individual therapy, family therapy, case management, medication management, and behavioral analysis for a minimum of two to three weeks. 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 met the criteria for RTC services. For dimension 1, the patient has been at serious risk of harm (score 4) due to repeated aggression towards others and danger towards self. The provider noted that the patient has shown labile and reactive behaviors. Indication or report of significant impulsivity and physical aggression, with poor judgment and insight, and that are significantly endangering to self and others. For dimension 2, the patient has demonstrated serious functional impairment (score 4) since she has not functioned well within the home setting without safety concerns towards self or others. 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 patient has severe comorbidities (score 5) given the concern for attention deficit hyperactivity disorder and depression. The patient also has past diagnosis of autism, bipolar disorder, focal seizures and hearing loss. Developmental disorder is present that seriously complicates, or is seriously compromised by, the presenting condition. For dimension 4A, the patients recovery environment has been moderately stressful (score 3) since the patients parents are separated and have a contentious relationship. The patient reported that she has witnessed her parents arguments. The patients parents are separated. This supports disruption in the family milieu. For dimension 4B, the patients recovery environment provides limited support (score 3) due to her parents attempts to care for the patient, but demonstration of limited skills to manage the patients high level of needs. Family has limited ability to respond appropriately to the patients developmental needs and problems. For dimension 5, the patient has exhibited poor resiliency and response to treatment (score 4). The records document that the patient continues to exhibit disruptive and unsafe behaviors with poor ability to meet expectations at home and school. The patient has a long history of severe mood and behavioral dysregulation with poor response to lower levels of care. Transitions with changes in routine are difficult even with a high degree of support. For dimension 6, the patient has been incompletely engaged in treatment (score 3) given her ability to appear calm in the emergency department but inability to control reactive behaviors. The provider noted that the patient continues to show poor insight. The patient requires a placement that specializes in children with autism and of which can provide multimodal mental health treatment. Inconsistent and avoidant relationship with clinicians and other care providers despite competent attempts at engagement. These findings give the patient a composite score of 26, which is consistent with medically monitored residence-based services. Therefore, the requested RTC services at a facility that specializes in children with autism and provides crisis residential level of care with individual therapy, family therapy, case management, medication management, and behavioral analysis for a minimum of two to three weeks 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 are not primarily for the economic benefit of the patient or provider. Final Result: The reviewer determined that the requested services 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.