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. 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, the patient met the criteria for the RTC services. For dimension 1, the patient was at some risk of harm (score 2) due to chronic poor impulse control, difficult family dynamics, history of suicidal attempt in 2020, and a history of severe substance abuse. The patient also referenced passive homicidal ideation toward his stepfather. The patient reported that learning Spanish was more important than math because he will need it when he kills someone and moves to Mexico, although the providers impression was that the patient was joking. On admission, the patient denied homicidal ideation. This supports a past history of fleeting suicidal and homicidal thoughts with no current ideation, plan, or intention and no significant distress. For dimension 2, the patient demonstrated moderate functional impairment (score 3), given his ongoing conflicted and troubled relationships with his family and limited accountability even while in therapy. The patient expressed that he is his true self when he uses substances. The records document conflicted, withdrawn, or otherwise troubled in relationships with peers, adults, and/or family, but without episodes of physical aggression. For dimension 3, the patient has a history of significant comorbidities (score 3), considering his depression and anxiety issues. The patients substance use is concerning and had a significant adverse effect on functioning and the patients psychiatric presentation. During treatment, the patient continued to require medication management. Substance abuse was present, with significant adverse effect on functioning and the patients presenting condition. For dimension 4A, the patients recovery environment was highly stressful (score 4). The records document that the patients parents are divorced, and the patients father has voiced lack of belief that the patient will improve. The patients trust with his mother is damaged, with dynamics still difficult, tense, and with severe conflict. The patient has a history of being unsafe in the home. These findings demonstrate serious disruption of family and social milieu. For dimension 4B, the patients recovery environment provided limited support (score 3) since his family was worn down and had limited ability to provide for the patients need for structure and support. The patients father expressed limited belief that the patient will be able to change or be safe. The patients family has limited ability to respond appropriately to childs developmental needs and/or problems or is ambivalent toward meeting these needs or addressing these problems. For dimension 5, the patient has shown poor resiliency and response to treatment (score 4) due to his history of outpatient, inpatient, and wilderness therapy prior to admission, with limited results. 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 was non-collaborative in treatment (score 4). The provider charted that the patient lacked accountability and responsibility for his own behaviors and did not accept age-appropriate responsibility in the perpetuation and consequences of his own actions such as his substance use. The patient continued to have difficulties taking accountability and externalized blame of his substance use issues. The patient did not accept age-appropriate responsibility in the development, perpetuation, or consequences of the problem. These findings give the patient a composite score of 23, which is consistent with medically monitored residence-based services. 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. All told, 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.