Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for residential treatment center (RTC) services at a facility that utilizes dialectical behavior therapy (DBT). 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. Applying the CALOCUS framework, this patient meets the criteria for RTC services at a facility that specializes in DBT. For dimension 1, the patient has been at significant risk of harm (score 3), due to passive suicidal ideation, aggressive behavior toward her mother, and periods of difficulty with self-care. There is indication or report of incidents of acting without thinking, or aggressive actions that endanger self or others. For dimension 2, the patient has demonstrated serious functional impairment (score 4) given her conflicts with parents and peers, aggression toward her mother, driving fast when angry, cannabis use. In addition, the patient has been declining self-care including not showering and struggling to feed herself. The patient has shown serious deterioration of interpersonal interactions with consistent conflict of otherwise disrupted interactions with others, which may include impulsive or abusive behaviors. Moreover, the patients failure to attend school or engage in consistent work demonstrates serious functional impairment. For dimension 3, the patient has minor comorbidities (score 2) including occasional, and self-limited episodes of substance use that are not immediately threatening or debilitating and that have no impact on the presenting condition and are not affected by it. The patient reports occasional cannabis use, which does not appear to have an impact on the patients presenting condition. For dimension 4A, the patients recovery environment is mildly stressful (score 2) considering her unstable living situation, lack of participation in work or school, and volatility in relationships. The patient has expectations at home or school that create discomfort. For dimension 4B, the patients recovery environment is supportive (score 2), due to her mothers involvement in planning treatment despite some conflict with the patient. Family caretaker is 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). Previous experience in treatment at low level of intensity has not been successful in relief of symptoms or optimal control of symptoms. In this case, outpatient treatment, including twice-weekly psychotherapy and multiple medication trials, have not prevented the patients recent decline in mood and functioning. For dimension 6, the patient has been constructive in treatment (score 2), due to her participation in treatment and motivation for treatment. The patient has been able to develop a trusting, positive relationship with clinicians and other care providers. These findings give the patient a composite score of 18, which is consistent with high intensity community-based services. Per CALOCUS, due to the patients score of 4 on risk of harm, the recommended level of care is medically monitored residence-based services. Given the patients serious functional impairment, the patient qualifies for Level 5B intermediate stay medically monitored residence-based services. The patient has shown significant disturbance in interpersonal interactions with consistent conflict or otherwise disrupted interactions with others, which may include impulsive or abusive behaviors as well as failure to attend school. Per CALOCUS, treatment at level 5B typically lasts up to 60 days. Moreover, the RTC services should be provided in a facility that utilizes DBT. In a recent review of psychological therapy for borderline personality disorder, researchers found that DBT may be better than usual treatment at reducing borderline personality disorder severity, self-harm and improving psychosocial functioning. For these reasons, the requested RTC services at a facility that utilizes DBT are medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested services are 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.