Appeal type: Medical Necessity
Decision: Upheld 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 (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 does not meet the criteria for RTC services. For dimension 1, the patient has been at significant risk of harm (score 3) due to her endorsements of severe urges to harm herself and continued suicidal ideation. She continued to engage in self-harm in the form of scratching and cutting herself. 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. For dimension 2, the patient has demonstrated moderate functional impairment (score 3) given her handwashing compulsions, which have increased during the period under review. On 3/3/21, the patient reported that she would likely fall into the same pattern of avoidant behaviors including sleeping all day and missing meals if she were discharged home. The patient has been compliant with schedule, hygiene routine, and meals, but this has been achieved while in the structured and contained environment of RTC. Recent gains and/or stabilization in functioning have been achieved while participating in treatment in a structured, protected, and/or enriched service. For dimension 3, the patient has no comorbidities (score 1) without any documented developmental delays, substance use disorders, or medical conditions. 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 moderately stressful (score 3). The records document that the patient has a strained relationship with her brother, she struggles to be open with her mother, and her father does not live in the home. There is a history of domestic violence and her brother has experienced problems with physical aggression and property destruction. This supports a disruption of family milieu. For dimension 4B, the patients recovery environment provides limited support (score 3) considering her strained relationship with her brother, divorced parents, and a variable relationship with her mother. The patients mother has been engaged in the patients treatment but there is no mention of the fathers participation. 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 has exhibited moderate or equivocal resiliency and response to treatment (score 3). The patients prior treatment history is notable for outpatient treatment in the fourth grade, engagement in outpatient therapy since November 2020, and psychiatric medication management since fourth grade. Previous experience in treatment at low level of intensity has not been successful in relief of symptoms or optimal control of symptoms. For dimension 6, the patient has been non-collaborative in treatment (score 4) since she has attended groups and therapy sessions but has not been fully engaged at times and does not utilize skills to manage her emotions. At times, patient is unwilling to talk about her feelings. The patient has expressed that she does not think that she is receiving the right treatment and she has been non-collaborative with her providers. The records suggest that the patient does not accept an age-appropriate responsibility role in development, perpetuation, or consequences of the problem. Accepts no age-appropriate responsibility in role development, perpetuation, or consequences of the problem. These findings give the patient a composite score of 20, which is consistent with Level 4 medically monitored community-based services, such as partial hospitalization program (PHP). Therefore, the RTC services provided were not and are not medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were not and are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. 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.