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

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement for residential treatment center (RTC) services. Findings:  The physician reviewer found that (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 was at serious risk of harm (score 4) due to chronic passive suicidal ideation at the RTC, and repeated statements that she would kill herself if she were sent home. The patients parents were not able to provide appropriate support or ensure her safety. The patient also has a history of a suicide attempt in October 2020. Current suicidal 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/or the familys ability to carry out the safety plan is compromised. For dimension 2, the patient demonstrated moderate functional impairment (score 3) given the conflict with her parents, withdrawal from friends, and school refusal. In this case, the patient maintained her safety and made significant progress while at the RTC. Recent gains and stabilization in functioning were achieved while participating in treatment in a structured, protected, and enriched service. For dimension 3, the patient has significant comorbidities (score 3) since her last use of alcohol was two weeks prior to her RTC admission, which she stopped while in the RTC. Recent substance use that had significant impact on the presenting condition was arrested due to use of a highly structured or protected setting or through other external means. For dimension 4A, the patients recovery environment was highly stressful (score 4). The provider noted that the patients parental verbal abuse was severe. This supports serious disruption of family or social milieu. For dimension 4B, the patients recovery environment provided limited support (score 3) given her parents inability to provide the support the patient needed at home, or to understand her emotional needs. Family has limited ability to respond appropriately to the patients developmental needs and problems or is ambivalent toward meeting these needs or addressing these problems. For dimension 5, the patient exhibited moderate or equivocal resiliency and response to treatment (score 3). The records document that the patient experienced worsening symptoms despite outpatient therapy and medication management, as well as a psychiatric hospitalization in late 2020. Previous treatment at low level of intensity has not been successful in relief of symptoms or optimal control of symptoms. For dimension 6, the patients parents were non-collaborative in treatment (score 4) due to their inability to understand the patients symptoms and needs, and their inability to provide the support she needed. Actively, frequently disrupts or stonewalls assessment and treatment. These findings give the patient a composite score of 24, which is consistent with Level 5 medically monitored residence-based services. Furthermore, the patient qualified for Level 5B intermediate stay medically monitored residence-based services since recent gains and stabilization in functioning were achieved while participating in treatment in a highly structured, protected, and enriched service, as demonstrated by the patients relative stability and improvement at the RTC. Per CALOCUS, the length of stay at Level 5B usually does not exceed 60 days. Moreover, the RTC services were 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 the convenience of the patient or provider. Given these findings, the RTC services were medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were 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.