Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement for residential treatment center (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 was at serious risk of harm (score 4) due to indication or report of significant impulsivity with poor judgment and insight, that are significantly endangering to self or others. This is demonstrated by the patients risky sexual behavior, history of multiple suicide attempts, substance use, and their continued impulsivity at the RTC. For dimension 2, the patient demonstrated serious functional impairment (score 4) given her conflict with her family and struggles to complete academic work. The records document serious deterioration of interpersonal interactions with consistent conflict or otherwise disrupted interactions with others, which may include impulsive behaviors. The patient has exhibited an inability to perform adequately even in a specialized school setting due to disruptive behavior, or inattentiveness. For dimension 3, the patient has significant comorbidities (score 3) considering her recent substance use that has significant impact on presenting condition has been arrested due to use of a highly structured or protecting setting or through other external means. The patients substance use stopped while at the RTC, but she continued to crave substances and glorify substance use, indicating a risk of relapse upon discharge. For dimension 4A, the patients recovery environment was moderately stressful (score 3) as evidenced by her conflict with her family, and risk of victimization due to her history of risky online interactions. The patient continued to demonstrate a lack of insight into the dangerousness of her behaviors, even after a visit from the police, which support a disruption of family and social milieu. For dimension 4B, the patients recovery environment was supportive (score 2). The records document that the patients parents participated in treatment and treatment planning. 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 shown poor resiliency and response to treatment (score 4). The records document that the patients symptoms persisted despite prior inpatient, RTC, PHP, and IOP treatment, as well as DBT. Thus, 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 was incompletely engaged (score 3) due to her tendency to deny or minimize problematic behaviors and their tendency to focus on her relationship with a peer at the RTC, rather than treatment goals. The patient frequently missed or was late for treatment appointments and was not invested in treatment, including medication and homework assignments. These findings give the patient a composite score of 23, which is consistent with medically monitored residence-based services. Per CALOCUS, the patient also qualified for Level 5B intermediate stay medically monitored residence-based services, based on significant disturbance in interpersonal interactions with consistent conflict and disrupted interactions, as evidenced by the patients conflict with parents and impulsivity and volatility at the RTC. Also, the patients substance use was temporarily arrested due to use of a highly structured or protected setting. Per CALOCUS, typical length of stay at Level 5B is up to 60 days. In this case, the patients total stay at the RTC was 30 days. Therefore, the RTC services were medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue 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.