Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage 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) medical, addictive 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, the requested RTC services are not supported as medically necessary for treatment of this patients behavioral health issues. The patient presents with some risk of harm (score 1) as he has denied suicidal ideation or urges to engage in self-harm. The patient has demonstrated moderate functional impairment (score 3) as he is having difficulties with school and has difficulty completing his IOP program assignments on time. Further, the patient presents with significant co-morbidities (score 3) including opposition defiant disorder (ODD), attention deficit/hyperactivity disorder (ADHD), a trauma and stressor related disorder, as well as cannabis abuse. The patients recovery environment is mildly stressful (score 2) given conflict with parents, which has improved during his treatment at intensive outpatient program (IOP). His parents have been supportive (score 2) as they have been involved in the patients treatment and recovery. The patient has shown limited response to treatment (score 3) as he can articulate the pros and cons of abstaining from use of cannabis, yet he endorses plans to continue to use cannabis. Further, the patient has been ambivalent about receiving mental health services. Overall, the patient has been obstructive to treatment (score 3) as he has been resistant to participate and change behaviors. His parents have been constructive in treatment and work with the patients providers (score 2). These findings give the patient a composite score of 19, which is consistent with high intensity community-based services, as provided in the IOP setting. The patient is currently receiving treatment at the IOP level of care. All told, the requested RTC services are not supported as medically necessary for treatment of this patients behavioral health issues. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. 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.