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 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 report of significant impulsivity and physical aggression, with poor judgment and insight, and that were significantly endangering to self or others. This was evidenced by the assault on a peer at his boarding school followed by multiple incidents of physical aggression at the RTC throughout 2019. For dimension 2, the patient demonstrated moderate functional impairment (score 3), considering his chronic and variably severe deficits in interpersonal relationships, but with ability to engage in socially constructive activities, and ability to maintain responsibilities. The records report physical aggression toward peers and disrespect toward peers and staff. The provider noted that the patient was able to participate in socially constructive activities, but on a limited basis. In addition, the patients recent gains in functioning have been achieved while participating in treatment in a structure, protected, and enriched service. Although struggling to respect healthy boundaries with peers and staff, the provider documented the patient minimized his bullying behavior when confronted by staff. For dimension 3, the patient has significant comorbidities (score 3) including reactive attachment disorder, which in this context can be considered a developmental disorder that has affected the patients ability to form and maintain healthy relationships. Reactive attachment disorder is co-occurring with oppositional defiant disorder and family relational problems. Given this, a developmental disability is present that may adversely affect the presenting condition and may require significant augmentation or alteration of treatment for the presenting co-morbid condition, or adversely affected the presented condition. For dimension 4A, the patients recovery environment was moderately stressful (score 3) considering his previous harassment by peers, as well as multiple moves between various residential programs over the past two years. The records support a disruption of family and social milieu. For dimension 4B, the patients recovery environment was supportive (score 2) due to his parents active participation in treatment. The patients family were 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) since previous treatment has not achieved complete remission of symptoms or optimal control of symptoms even with intensive and repeated exposure to treatment. The patient has been treated in multiple RTC facilities and a wilderness program. By discharge, the patient showed overall stability in regulating his emotional states and interpersonal interactions in addition to improvement in respecting reciprocal boundaries, empathy, and exhibiting more prosocial boundaries. For dimension 6, the patient was incompletely engaged in treatment (score 3). The providers report the patient was avoidant and condescending during a group service project, minimized his bullying behavior when confronted by staff, and he started to regress into old patterns of not respecting healthy boundaries of peers and staff. The patient minimized or rationalized distressing behaviors and consequences. These findings give the patient a composite score of 22, which is consistent with medically monitored community based services. As noted in CALOCUS, due to the patients score of 4 on risk of harm, the recommended level of care was Level 5 medically monitored residence-based services. In addition, the patient qualified for Level 5C, long-term medically monitored residence-based services due to chronic and severe deficits in interpersonal relationships, as well as minimal past response to treatment, as evidenced by his continued episodes of aggression and struggles with attachment and boundaries, despite extensive residential treatment. Per CALOCUS, this type of RTC has the capacity to treat adolescents with long-term and persistent disabilities that require extended rehabilitation and skill building in order to develop capacity for community living. These facilities will provide intensive treatment as described for all Level 5 programs and the length of stay will vary from two months to a year. In this case, the patients longstanding difficulties and aggressive behaviors, which persisted even after multiple residential placements, justified a long-term RTC admission. The patients 11-month stay at the RTC falls within the CALOCUS guidelines. Therefore, 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.