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. Findings:  The physician reviewer found that 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 recent suicide attempt and impulsivity, including outbursts involving throwing objects, trying to climb into a tree with the intention to jump, and suicidal thoughts. Indication or report of significant impulsivity with poor judgment and insight, that are significantly endangering to self or others. For dimension 2, that patient has demonstrated serious functional impairment (score 4) given her angry outbursts and inability to perform even in a specialized school setting due to disruptive behavior. The patient was dismissed from one school due to suicidality, and then transferred to a school offering flexible and individualized learning, and then was dismissed again in October 2019 due to concerns about suicidality and self-harm. Inability to perform adequately even in a specialized school setting due to disruptive behavior, or inattentiveness. For dimension 3, the patient has no reported comorbidity (score 1). The records document that the patient is in good physical health, with no developmental disorders or history of substance abuse. 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 mildly stressful (score 2) stressful environment, due to stress related to transitions between her parents homes and adjusting to their lives and her siblings. This supports a significant transition requiring adjustment, such as change in household members, or new school or teacher. For dimension 4B, the patients recovery environment has been supportive (score 2) due to her parents participation in family therapy and treatment planning. Family caretakers are willing and able to participate in treatment if requested to do so and have capacity to effect needed changes. For dimension 5, the patient has exhibited poor resiliency and response to treatment (score 4), due to continued dysregulated emotions and suicidality despite 11 years of outpatient therapy, psychiatric hospitalization, 60 days of PHP treatment, and intensive DBT-focused outpatient treatment prior to admission to RTC. While at the RTC, the patient has shown dysregulation, impulsivity by eloping from the facility, and continued self-harm. 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 constructive in treatment (score 2) due to her cooperation with treatment at the RTC. The patient passively cooperates in treatment planning and treatment. These findings give the patient a composite score of 19, which is consistent with high intensity community-based services. Per CALOCUS, the patients scores of 4 on risk of harm and functional status support treatment at Level 5, medically monitored residence-based services. Furthermore, the patient qualifies for Level 5C, long-term medically monitored residence-based services due to minimal past response to treatment and inability to maintain any gains achieved outside an intensive and highly structured setting. Per CALOCUS, at Level 5C, the length of stay will vary from two months to one year. In this case, the patient completed 11 years of psychotherapy, several months of outpatient psychiatric treatment, a psychiatric hospitalization, PHP, and intensive outpatient DBT treatment without making sustained progress. For these reasons, 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.