Appeal type: Medical Necessity
Decision: Overturned

Findings:  The physician reviewer found that The patients parent 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 meets the criteria for RTC services. For dimension 1, the patient was at serious risk of harm (score 4) due to a history of suicidality and excessive substance use as well as multiple overdoses. The patient demonstrated impulsivity as evidenced by leaving the RTC without permission and punching objects while at the RTC and during her inpatient hospitalization. The patient exhibited reckless behavior including exchanging sex for drugs. The records support indication or report of significant impulsivity and/or physical or sexual aggression, with poor judgment and insight, that were significantly endangering to self or others. For dimension 2, the patient demonstrated serious functional impairment (score 4), given her elopement from the RTC, acts of physical aggression, and emotional dysregulation during family therapy. The patient showed serious deterioration of interpersonal interactions with consistent conflict or otherwise disrupted interactions with others, which included impulsive and abusive behaviors. For dimension 3, the patient has major comorbidities (score 4). The records document that the patient took an overdose of Xanax, went to school and then blacked out. The patient reported that she has engaged in sexual acts with multiple partners while intoxicated. The patient has a history of seizure after using multiple substances. Uncontrolled substance use was present that posed a serious threat to health if unabated and impeded recovery from the presenting condition. For dimension 4A, the patients recovery environment was moderately stressful (score 3) due to past exposure to abuse in the home environment and her caregivers difficulties with setting boundaries. The records document disruption of family and social milieu. For dimension 4B, the patients recovery environment provided limited support (score 3) since the patients mother and stepfather were participating in family therapy, but more work needed to be done to stabilize the patients home environment. The patients family or primary caretakers demonstrated only partial ability to make necessary changes during treatment. For dimension 5, the patient has shown poor resiliency and response to treatment (score 4). The records document that previous treatment has not achieved complete remission of symptoms or optimal control of symptoms, even with intensive and repeated exposure to treatment. In this case, the patient continued to engage in reckless and impulsive behavior after multiple inpatient hospitalizations, and while at the RTC, as demonstrated by physical aggression and eloping from the RTC without permission. For dimension 6, the patient was constructive in treatment (score 2) due to her active participation in her therapeutic interventions. The patient passively cooperated with treatment planning and treatment. These findings give the patient a composite score of 24, which is consistent with Level 5, medically monitored residence-based services, due to serious risk of harm and serious functional impairment. Furthermore, the patient qualified for Level 5B, intermediate stay medically monitored residence-based services due to recent suicidality and impulsivity, disturbance in interpersonal interactions, co-occurring substance abuse and mental health disorders, and the familys difficulty in adequately responding to her needs. In addition, the patient continued to struggle after two inpatient hospitalizations. Per CALOCUS, the length of stay at Level 5B usually does not exceed 60 days. In this case, the patients total stay at the RTC was within this range. Moreover, the RTC services were in accordance with the generally accepted standards of mental health and substance use disorder care, clinically appropriate in terms of type, frequency, extent, site, and duration and not primarily for the convenience of the patient or provider. Therefore, the RTC services were medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.