Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for dialectical behavior therapy (DBT)-based treatment plan including one DBT individual therapy session per week, one DBT skills training group per week, and one DBT skills training group per week. Findings:  The physician reviewer found that (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 the requested DBT-based treatment plan. For dimension 1, the patient is at significant risk of harm (score 3) due to chronic suicidal ideation and repeated self-harm. The patient endorsed active suicidal ideation with the last incident one month before intake with thoughts of taking poison. This supports significant current suicidal ideation with some intent and plan, with an ability for the patient to contract for safety and carry out such a safety plan. For dimension 2, the patient has demonstrated moderate functional impairment (score 3) given the need for specialized school placement. Some evidence of minor failures of function in any of several areas of living including school. These periodic failures are time limited. For dimension 3, the patient has no co-morbidities (score 1) considering the lack of a substance use disorder, developmental disorder, or major medical condition. No evidence of medical illness, substance abuse, developmental disability, or psychiatric disturbances apart from the presenting condition. For dimension 4A, the patients recovery environment is mildly stressful (score 2) based on the stress associated with transitioning between parents and grandparents households, and the disruptions caused by the pandemic. Significant transition requiring adjustment, such as change in household members, or new school or teacher. For dimension 4B, the patients recovery environment is supportive (score 2). The provider noted that the patients parents have been active participants in the patients treatment. 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). The provider noted that the patient did not respond to medication trials or psychotherapy in the community. 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 constructive in treatment (score 2) due to her participation in 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 16, which is consistent with low intensity community-based services. Per CALOCUS, the recommended level of care in this case is Level 3 high intensity community-based services, due to the patients lack of response to lower levels of care. Per CALOCUS, at Level Three, Service intensity averages approximately three days per week at least two or three hours per day. The patients DBT program falls within this guideline. Moreover, DBT is an appropriate modality for this patient given her self-harm with traits of borderline personality disorder, suicidal ideation, and depressive symptoms . DBT has been shown to lead to significantly more favorable outcomes with respect to reduction in the frequency of self-harm behavior both in the short- and long-term perspective.Given these findings, the requested DBT-based treatment plan including one DBT individual therapy session per week, one DBT skills training group per week, and one DBT skills training group per week is medically necessary to treat this patients illness in accordance with the generally accepted standards of mental health and substance use disorder care, it is clinically appropriate in terms of type, frequency, extent, site, and duration, and it is not primarily for the convenience or benefit of the patient or provider. 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.