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 180 days of Level 5 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 180 days of Level 5 RTC services. For Dimension 1, the patient has been at significant risk of harm (score 3) due to ongoing poor impulse control and frustration tolerance. The patient has made threats of suicide and carried out an actual suicidal gesture of eating deodorant while at the RTC. The provider noted that the patient has poor coping skills to deal with stress. Significant current suicidal ideation with some intent and plan, with an ability for the patient to contract for safety and carry out a safety plan. (sub a)For Dimension 2, the patient has demonstrated serious functional impairment (score 4) given his poor functioning at home and extreme difficulties with mood and behavioral regulation. 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 patient has significant comorbidities (score 3) considering his autism, ADHD, and depression, with poor functioning at home and poor mood and behavioral regulation. In addition, the patient has parent-child relational problem and academic or educational problem. Developmental disability is present that may adversely affect the presenting condition and may require significant augmentation or alteration of treatment for the presenting condition or comorbid condition, or adversely affects the presenting condition. For Dimension 4A, the patients recovery environment is highly stressful (score 4) as the patients conflict with his caregiver is stressful and involves ongoing issues. Serious disruption of family or social milieu due to illness, death, divorce, or separation of parent and adolescent.For Dimension 4B, the patients recovery environment provides limited support (score 3). The records document that the patients caregiver has limited ability to enforce rules, with concerns about the patients tantrums, which escalate when the patient is given boundaries. Family has limited ability to respond appropriately to the patients developmental needs and/or problems or is ambivalent toward meeting these needs or addressing these problems. For Dimension 5, the patient has exhibited poor resiliency and response to treatment (score 4) as the provider noted the patient continues to demonstrate poor insight and judgment. Previous treatment has not achieved complete remission of symptoms or optimal control of symptoms even with intensive and/or repeated exposure to treatment. For dimension 6, the patient has been non-collaborative in treatment (score 4). The provider reported that the patient is disruptive in milieu and interferes with group therapy. Actively, frequently disrupts or stonewalls assessment and treatment. These findings give the patient a composite score of 25, which is consistent with Level 5 medically monitored residence-based services. Per CALOCUS, the patients score of 4 on functional status, also supports Level 5 services. The patient has consistently demonstrated poor treatment insight, with poor mood and behavioral regulation. Based on the CALOCUS long-term residential care criteria, the patient further meets 5C criteria for extended RTC stay given his minimal past response to treatment and inability to maintain any gains achieved outside an intensive and highly structured setting, persistent symptoms despite extensive and intensive treatment exposure, and chronic inability to understand disability, recovery or personal responsibility, or to relate to other individuals.There are concerns for the patients ability to function safely outside of a highly structured setting. RTC level of care is appropriate with goal of further assessment and skills training and will provide appropriate medication management. For these reasons, the requested 180 days of Level 5 RTC services are medically necessary for treatment of this patient. 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 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.