Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested 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 environments (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 60 days. For dimension 1, the patient has been at serious risk of harm (score 4) due to multiple past suicide attempts, chronic self-harm, and reported suicidal ideation at the RTC. Also, the patients impulsivity, including hypersexuality, places her at increased risk of harm. Indication or report of significant impulsivity with poor judgment and insight, that is significantly endangering to self or others. For dimension 2, the patient has demonstrated moderate functional impairment (score 3) given her inability to attend school for the past two months and conflict with her family members. She has stabilized in the protected and structured environment of the RTC. Recent gains and stabilization in functioning have been achieved while participating in treatment in a structured, protected, and enriched service. For dimension 3, the patient has minor comorbidities (score 2) due to occasional use of cannabis, alcohol, and nicotine. Substance use has not been the focus of her treatment. Occasional, self-limited episodes of substance use are present that show no pattern of escalation, with no indication of adverse effect on functioning or the presenting condition. For dimension 4A, the patients recovery environment is mildly stressful (score 2). The provider reported that the patient has high conflict with her father and other family members, as well as past emotional trauma with father. This supports expectations for performance at home or school that create discomfort. For dimension 4B, the patients recovery environment has been supportive (score 2) since her parents have participated in treatment 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) considering her lack of improvement after multiple recent attempts at PHP and two recent inpatient hospitalizations. 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). The providers noted that the patient has been an active participant in individual and group therapy. Able to develop a trusting, positive relationship with clinicians and other care providers. These findings give the patient a composite score of 19, which is consistent with high intensity community-based services. Per CALOCUS, the patients score on risk of harm supports Level 5, medically monitored residence-based services. Furthermore, the patient qualifies for Level 5B, intermediate stay medically monitored residence-based services since the patient experiences some suicidal or homicidal ideation with some ambivalence or is highly distressed with some history of harm to self or others. Impulsivity may be present and the risk of engaging in destructive behaviors is significant in an unstructured environment. In this case, the patient was recently hospitalized twice for suicidality, and she has also participated in a PHP, but her symptoms have persisted. Her impulsive behaviors place her at continued risk of harm. CALOCUS states that the length of stay at Level 5B usually does not exceed 60 days. RTC services are medically necessary for 60 from the date of admission. Therefore, RTC level of care was and is medically necessary for treatment of this patient as defined by California Health and Safety Code section 1374(a)(3)(A). 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.