Appeal type: Medical Necessity
Decision: Overturned

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 meets the criteria for RTC services. For dimension 1, the patient has been at serious risk of harm (score 4) due to her history of multiple suicide attempts such as choking, resulting in inpatient hospitalizations. The patient has continued to engage in self-harm attempts while in RTC with suicidal ideation. Prior to admission, the patient was noted to self-cut, bang her head, and punch her siblings. This supports current suicidal ideation with past history of carrying out such behavior. The patient has expressed some ambivalence about carrying out the safety plan. For dimension 2, the patient has demonstrated serious functional impairment (score 4) given her persistent and escalating self-harm behaviors and aggression over the past few months. Serious deterioration of interpersonal interactions with consistent conflict or otherwise disrupted interactions with others, which may include impulsive or abusive behaviors. For dimension 3, the patient has minor comorbidities (score 2). Per the provider, the patient has depression, anxiety, and ADHD, as well as a learning impairment with an individualized education plan. Transient, occasional, stress-related psychiatric symptoms are present that have no discernable impact on the presenting condition. For dimension 4A, the patients recovery environment has been moderately stressful (score 3). The records document that the patients parents are divorced, and the patient only sees her father once in a while.  The patient is noted to have significant conflict with her two siblings and her mother. This supports disruption of family and social milieu. For dimension 4B, the patients recovery environment provides limited support (score 3), considering the patients aggression toward her siblings, conflict with her mother, and the absence of her father. The family has limited ability to respond appropriately to the patients developmental needs and/or problems, or is ambivalent toward meeting these needs, or addressing these problems. For dimension 5, the patient has exhibited poor resiliency and response to treatment (score 4), given her previous treatment at the psychiatric inpatient and PHP levels of care. 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) due to her self-harm attempts while in the RTC, in addition to poor insight and impulse control. This demonstrates that the patient was unable to accept others definition of the problem and its consequences. These findings give the patient a composite score of 23, which is consistent with medically monitored residence-based services. Per CALOCUS, the patients scores of 4 on risk of harm and functional impairment support Level 5 medically monitored residence-based services. Overall, the patient has demonstrated severe mood and behavioral dysregulation concerns, with significant self-harm and suicidal ideation. The patients anxiety is high, and she has limited treatment insight. Given these findings, 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.