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 45 days of residential treatment center (RTC) services from a facility that has a therapist trained in providing applied behavior analysis (ABA) services, or 30 days of RTC services from a facility that has a therapist trained in providing ABA services, or 45 days or in the alternative 30 days of 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. For dimension 1, the patient is at extreme risk of harm (score 5) due to the patients recent suicide attempt via overdose. At the time of overdose, the patient was under the influence of alcohol and another substance, and she asked her father to let her die en route to the emergency department. She required intubation in the intensive care unit (ICU) to prevent respiratory failure. The records support current suicidal ideation or such intentions with a plan and available means to carry out this behavior. For dimension 2, the patient has been demonstrating serious functional impairment (score 4) considering her difficulties with social interactions with peers, and family. She is attending school with an individualized education plan (IEP) and has been struggling to complete her last semester of school due to her illnesses. This supports an inability to perform adequately even in a specialized school setting due to disruptive behavior or inattentiveness. For dimension 3, the patient presents with severe comorbidities (score 5) given her diagnosis of autism, depression, post-traumatic stress disorder (PTSD), eating disorder, and substance use disorders. Prior treatment with ABA services were beneficial and allowed her to learn to adapt and mainstream as a child, but she has issues interacting with peers at the adolescent stage. She recently required admission to the ICU following an overdose attempt. A developmental disorder is present that seriously complicates, or is seriously compromised by, the presenting condition. For dimension 4A, the patients recovery environment is highly stressful (score 4) as she struggled to complete school due to her illnesses, was recently sexually assaulted by peers, and experienced conflict with her parents before her suicide attempt. This supports serious disruption of family and social milieu due to torment and sexual abuse. For dimension 4B, the patients recovery environment is supportive (score 2) considering her parents active involvement in her treatment planning. Family 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). The records document that she failed treatment in an eating disorder RTC, partial hospitalization program (PHP) and intensive outpatient program (IOP) before her suicide attempt. 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 incompletely engaged in treatment (score 3) as she has been slow to disclose her trauma, alcohol use, and other substance use to her providers and family. The patient has experienced ambivalent, avoidant, or distrustful relationships with clinicians and other providers. These findings give the patient a composite score of 27 which is consistent with medically monitored residence-based services. Due to her history of autism that responded well to ABA services in the past, as well as her diagnoses of PTSD, alcohol use disorder, cannabis use disorder, and possible other substance use disorder, it is recommended that the RTC also provide ABA services. The patients ongoing life stress meets the Level 5B criteria for intermediate RTC stay. Given these findings, the requested 45 days of RTC services from a facility that has a therapist trained in providing ABA services is 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 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.