Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

The patient is a 16-year-old male with a history of severe emotional and behavioral dysregulation, including property damage and conflicts. The records noted a history of school avoidance/refusal due to sleep deprivation, anhedonia and somatic complaints. The patientas parent has requested reimbursement for residential mental health treatment for children and adolescents provided from 10/02/19 through 4/24/20. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of this patient. The physician reviewer found that The Child and Adolescent Level of Care Utilization System (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) medical, addictive and psychiatric comorbidity; (4) recovery environment (a. stressors and b. supports); (5) treatment and recovery history; and (6) engagement. The composite score helps 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. In this case, the records support a score of 4. The patient has a history of significant physical and verbal aggression towards others as well as threats to harm himself. The records document a psychiatric hospitalization in April 2019 due to acute suicidality via plan to jump off an apartment terrace. For dimension 2 a Function: This dimension assesses the degree to which a person is able to fulfill responsibilities for a given age level.  In this case, the records support a score of 4. The patient has a history of severe school avoidance, conflicts with parents, frequent threats of self-harm, multiple depressive symptoms and suicidal ideation with poor impulse/frustration tolerance. For dimension 3 a 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. In this case, the records support a score of 3. The patient has significant comorbidities, including major depressive disorder, generalized anxiety disorder and parent-child relational problem. For Recovery Environment dimension 4A- Stress: This dimension assesses the stressors in the environment, social circumstances, and interpersonal relationships. In this case, the records support a score of 4. The patient appears to have had a stressful environment involving severe conflicts with his father and parental divorce. For Recovery Environment dimension 4B- Support: This dimension assesses the presence of family and social support to augment the recovery environment. The records support a score of 3. The patientas support is limited. His parents appear at a loss as to how to parent the patient and are overwhelmed. The records document multiple severe conflicts with his father.  For dimension 5- Treatment and Recovery History: This dimension assesses success or failure to make use of treatment and natural support that fosters resilience. In this case, the records support a score of 4. The patient had a history of limited response to outpatient therapy and continued to decompensate while at home and in the community, with inability to attend school or maintain safety within the home. For dimension 6 a Engagement: With regard to engagement of the patient, the records support a score of 3. Per the notes, despite outpatient therapy and medication management, the patient had limited progress and insight. Thus, the patient has a composite score of 25, which is consistent with Level 5, residential level of care. The patientas scores of 4 in risk of harm criteria and functional status criteria also automatically qualify the patient for Level 5 services. This patient has consistently demonstrated multiple lagging skills in the social and emotional realms with inability to function safely outside of a highly structured setting. Therefore, residential mental health treatment for children and adolescents provided from 10/02/19 through 4/24/20 was medically necessary for the treatment of this patient.