Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement and authorization and coverage for residential treatment center services.The Child and Adolescent Level of Care Utilization System (CALOCUS) provides a reliable 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. The records note that the patient had a recent history of suicidal ideation, as well as recent impulsive and dangerous behavior (taking her parent's car with a plan to drive off a bridge) showing poor judgment and insight. The patient was also suspected of engaging in self-harm at the residential treatment center. [Score 4  Serious Risk of Harm]For dimension 2  Functional Status. This dimension assesses the degree to which a person is able to fulfill responsibilities for a given age level. The records describe the patient as being socially isolated. The patient was also noted to have decreased sleep and appetite. This reflects that the patient was withdrawn in her relationships and that her self-care was concerning. [Score 3  Moderate Functional Impairment]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 no reported medical or developmental disorders and no reported history of substance abuse. [Score 1  No Co-Morbidity]For Recovery Environment dimension 4A- Stress. This dimension assesses the stressors in the environment, social circumstances, and interpersonal relationships. The patient has a history that includes past bullying and sexual abuse, followed by court cases. This corresponds with danger or threat in the community and a history of harassment by peers. [Score 3  Moderately Stressful Environment]For Recovery Environment dimension 4B- Support. This dimension assesses the presence of family and social support to augment the recovery environment. The patients recovery environment was supportive, due to her parent's participation in treatment and treatment planning. [Score 2  Supportive Environment]For dimension 5- Treatment and Recovery History. This dimension assesses success or failure to make use of treatment and natural support that fosters resilience. The patient had poor resiliency and/or response to treatment, due to her lack of improvement after multiple recent attempts at higher levels of care (IOP and five recent inpatient hospitalizations). [Score 4 - Poor Resiliency and/or Response to Treatment]For dimension 6  Engagement. This dimension assesses a persons understanding of their illness and treatment, and their ability and willingness to engage in the treatment process. The patient was incompletely engaged, due to her difficulty being honest about her behaviors and symptoms at the residential treatment center. [Score 3  Incompletely Engaged]These findings give the patient a composite CALOCUS score of 20, which is consistent with Level 4: Medically Monitored Community Based Services. The patients score of 4 in the Risk of Harm dimension, however, automatically qualifies her for Level 5: Medically Monitored Residence Based Services. Furthermore, the patient qualifies for Level 5B: Intermediate Stay Medically Monitored Residential Programs, based on the following criterion: `Child or adolescent experiences some suicidal or homicidal ideation with some ambivalence, or is highly distressed with some history of harm to self or others. Impulsivity may be present and the risk of engaging in destructive behaviors is significant in an unstructured environment.` In this case, the patient has been hospitalized five times in recent months, with four hospitalizations for suicidality. She has not responded to intensive outpatient treatment. The next logical step is a residential stay for a longer period than a typical inpatient hospitalization. Per CALOCUS, the length of stay at Level 5B `usually does not exceed 60 days`. Accordingly, the residential treatment center services at issue and requested services were, and are, medically necessary to treat the patients condition.Final Result: The reviewer determined that the services at issue and requested services were, and are, medically necessary to treat the patient's 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.