Appeal type: Medical Necessity
Decision: Upheld

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 American Association of Community Psychiatrists Level of Care Utilization System (CALOCUS) provides a reliable framework for determining the appropriate level of care for adults 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, this patient does not meet the criteria for RTC services. For dimension 1, the patient has been at significant risk of harm (score 3) due to a history of suicidal ideation and self-harm. The patient is not currently endorsing suicidal ideation while in treatment. However, the patient has a significant history of alcohol use and cannabis use with daily to near-daily use. She has been sober while in treatment. No active suicidal or homicidal ideation, but extreme distress and a history of suicidal behavior. For dimension 2, the patient has demonstrated mild functional impairment (score 3) given her gains in her functioning while in treatment. However, the patient is eating only 50% of her meals. The provider noted that the patient exhibits a flat affect, and she continues to endorse anxiety and cravings for substances. These gains are recent and have been achieved while in residential treatment. The patient demonstrates significant improvement in function following a period of deterioration. For dimension 3, the patient has significant comorbidities (score 3) including daily cannabis use, daily to near-daily consumption of alcohol, and intermittent use of various other substances, including opioids. The patient has been abstinent while in treatment and endorses continued cravings for substances rated 2/5. Substance abuse is present, with significant adverse effect on functioning and the presenting condition. For dimension 4A, the patients recovery environment is highly stressful (score 4) given her tense relationship with her parents, history of trauma, and body image and self-esteem issues. The patient reported that she has lost friends to addiction. This suggests that the patient associates with peers who use substances, and she may have difficulty avoiding exposure to substance use and its effects. For dimension 4B, the patients recovery environment has been supportive (score 2). The provider noted that the patients parents have been supportive of the patient but there is tension in the relationship due to poor communication. Family caretakers are 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 exhibited moderate or equivocal resiliency and response to treatment (score 3) due to her history of outpatient treatment with ongoing significant substance use prior to entering RTC. Previous experience in treatment at low level of intensity has not been successful in relief of symptoms or optimal control of symptoms. For dimension 6, the patient has been incompletely engaged in treatment (score 3) since the records document that she has been engaged in treatment during residential stay, but she remains intermittently guarded and withdrawn. Ambivalent, avoidant, or distrustful relationship with clinicians and other care providers. These findings give the patient a composite score of 21 which is consistent with Level 4 medically monitored community-based services. For these reasons, the psychiatric RTC services were not and are not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the services at issue were not and 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.