Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Residential Treatment Center level of care. Findings:  The physician reviewer found that (CALOCUS) provides a framework for determining the clinically appropriate level of care for a child or adolescent in 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 (Astressors, and B-supports); (5) resiliency and treatment history; and (6) treatment acceptance and engagement. The composite score is then used to determine the level of care needed.For dimension 1  Risk of Harm. This dimension assesses potential for harm to self or others, or having harm inflicted upon them. When the services at issue were first provided, the patient had shown little progress from her initial presentation. She had no active suicidal intentions, but she continued to have severe distress in combination with a history of suicidal behaviors and ideation. The patients score at the beginning of this period was 3, and this score would remain consistent throughout the period when the services at issue were provided. [Score 3  Significant Risk of Harm, for the entire period under consideration]For dimension 2  Functional Status. This dimension assesses the degree to which a person is able to fulfill responsibilities and be capable of maintaining stable relationships with others relative to their baseline and others of their age level. At the time of admission, the patient had serious disruption of her relationships and her ability to interact appropriately with others, including many impulsive and aggressive behaviors. The patients score during the initial period when services were provided was 4. Over the course of treatment, the patient made progress in this dimension, and her functioning improved enough to justify a reduction in score to 3 during the later period when the services at issue were provided. [Score 4  Serious Functional Impairment, during the initial period when services at issue were provided; Score 3  Moderate Functional Impairment, during the later period when services at issue were provided]For dimension 3  Comorbidity. This dimension assesses the co-existence of disorders across four domains (psychiatric, substance use, medical or developmental) that may complicate the course of treatment. The patient had significant substance use in the past that impacted her mental health, but it was at least temporarily arrested due to her participation in residential treatment settings over the past year. The patients score on this dimension would have been 3, and remained so throughout her treatment. [Score 3  Significant Co-Morbidity, for the entire period under consideration]For dimension 4A  Recovery Environment  Stress. This dimension assesses the stressors in the environment, social circumstances, and interpersonal relationships. The patient had significant disruption of her family and social situation with placement outside her home. Antagonistic relations with her parents contributed to the stress she experienced. Following admission, the patients score would have been 3, and remained so throughout her treatment. [Score 3  Moderately Stressful Environment, for the entire period under consideration]For dimension 4B  Recovery Environment  Support. This dimension assesses the presence of family and social support to augment the recovery environment. At the time of the patients admission, her parents were not sources of support and felt that they could not manage her needs if she were at home. She had no other supports at the time of admission. At the time of admission, the patients score on this dimension was a 3. The patients family became more engaged in treatment, however, and during the later period when services at issue were provided, a score of 2 would have been most appropriate. [Score 3  Limited Support in Environment, during the initial period when services at issue were provided; Score 2  Supportive Environment, during the later period when services at issue were provided] Incompletely Engaged, during the later period when services at issue were provided]These findings give the patient two composite CALOCUS scores, one score for the initial period when services at issue were provided, and a second score for the later period when services at issue were provided. The patients composite CALOCUS score for the initial period when services at issue were provided is 24, which is consistent with Level Five: Medically Monitored Residence Based Services. The patients score of 4 for dimension 2 also constituted independent criteria for admission to this level for this period. Therefore, the Residential Treatment Center level of care provided during the initial period when services at issue were provided was medically necessary to treat the patients medical condition.There was no significant indication that the patients CALOCUS dimensional scoring had consistently changed until the patient returned from a home visit that went well. Both the patient and her parents indicated a desire for her to return home at that time. Therefore, the patients score on dimension 2 could be reduced to 3, and her scores for dimension 4B (score reduced to 2), dimension 5 (score reduced to 3) and dimension 6 (score reduced to 3) were also reduced as of this date. Given these score changes, the patients composite CALOCUS score for the later period when services at issue were provided is 20, which is consistent with Level Four: Medically Monitored Community Based Services. Accordingly, the Residential Treatment Center level of care provided during the later period when services at issue were provided was not medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the services at issue were partially medically necessary to treat the patient's medical condition. Therefore, the Health Plans denial should be partially overturned.Credentials/Qualifications: The reviewer is board certified in 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.