Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement 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) 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 did not meet the criteria for RTC services. For dimension 1, the records document that the patient had a recent psychiatric hospitalization and a past suicide attempt (score 1). However, no additional information is offered regarding the patients  level of risk at the time of admission. There is no indication that the patient was suicidal or aggressive during his time in the wilderness program. In the absence of this data, the patients risk of harm cannot be scored. For dimension 2, without an initial assessment, there is a lack of information to determine the patients functional status at the time of admission (score 1). He appears to have been able to function within the structure and expectations of the wilderness program. Given these findings, the patients functional status cannot be assessed.  For dimension 3, although the patients diagnoses at discharge included a reference to substance use, he reportedly did not meet diagnostic criteria for a substance use disorder. No additional information is provided and there is also no medical history in the chart. Thus, a co-morbidity score cannot be determined (score 1). For dimensions 4A, and 4B details about the patients  recovery environment are not provided for review (score 1). The record indicates that he experienced conflict with his parents. Without any additional information about the patients environment prior to admission, the patient receives minimal scores for environmental stress (score 1) and environmental support (score 1). For dimension 5, the records provide a medication history and refer to a past hospitalization, but the extent and intensity of prior treatment is not described in the records (score 1). For dimension 6, the records indicate that the patient participated actively in the wilderness program (score 2). These findings give the patient a composite score of 8, which is consistent with basic services for preventive maintenance. Based on the lack of information provided to support the six CALOCUS dimensions, the  RTC services were not medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were 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.