Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement for residential treatment center (RTC) services. The American Association of Community Psychiatrists Level of Care Utilization System (CALOCUS) provides a reliable framework for determining the appropriate level of care for adults 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) medical, addictive 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, the patient met the criteria for RTC services. For dimension 1, the patient was at serious risk of harm (score 4) due to one previous suicide attempt in which she overdosed on an antidepressant and a history of self-harm. The patients suicide attempt was quite serious as she was hospitalized in an ICU for four days as a result. She continued to endorse suicidal ideation with a plan to overdose on medications upon return home. The patient was noted to have stashed medications for use on her return home. The patients parent also reportedly discovered a knife hidden in her mattress. The patient continued to express feelings of hopelessness. Current suicidal ideation with either clear, expressed intentions and past history of carrying out such behavior. The patient expressed ambivalence about carrying on the safety plan. For dimension 2, the patient demonstrated serious functional impairment (score 4) given her need for either inpatient psychiatric or RTC services over five of the last six months. The provider charted that the patient was profoundly depressed, and she endorsed feelings of hopelessness. The patient indicated that she was isolating. The patient also reported that she stopped eating for two weeks while at home and she lost 12 pounds. The patient had no desire to add activities to her routine. This supports consistent failure to achieve self-care at levels appropriate to age and developmental level as well as serious disturbances in physical function. For dimension 3, the patient has major comorbidities (score 4) with a diagnosis of anorexia nervosa. The patient reportedly lost 12 pounds in the two weeks prior to hospitalization due to restricting intake. The patients anorexia has resulted in amenorrhea. She also has a history of asthma and gastroesophageal reflux disease. Medical conditions were present that would adversely affect and be affected by the presenting condition. For dimension 4A, the patients recovery environment was moderately stressful (score 3). The provider noted that the patient has a toxic friendship, and the patient identifies this friend as her only source of support. The patient has a history of anorexia, which resulted in weight loss of 12 pounds in the two weeks prior to admission. Serious illness for prolonged period, constant pain, or other disabling condition. For dimension 4B, the patients recovery environment was supportive (score 2) since the patients parents were noted to be supportive and engaged in the patients treatment. Family caretakers were willing and able to participate in treatment if requested to do so and had capacity to effect needed changes. For dimension 5, the patient has exhibited poor resiliency and response to treatment (score 4) since she has been psychiatrically hospitalized at least twice and in a RTC program prior to admission. Previous treatment has also included outpatient treatment and a partial hospitalization program (PHP). The patient has been treated with multiple antidepressant medications with limited or no benefit. The patients symptomatology has persisted despite multiple treatment attempts at various levels of care. Previous treatment has not achieved complete remission of symptoms or optimal control of symptoms even with intensive and repeated exposure to treatment. For dimension 6, the patient was non-collaborative in treatment (score 4). The provider noted that the patient continued to express feelings of hopelessness and she failed to complete therapeutic assignments. The patient minimized her behaviors and resisted the consequences of her behaviors. The patient accepted no age-appropriate responsibility role in development, perpetuation, and consequences of the problem. These findings give the patient a composite score of 25, which is consistent with Level 5 medically monitored residence-based services. Per CALOCUS, the patients scores of 4 for risk of harm,  functional status, and comorbidity also support treatment at Level 5 medically monitored residence-based services. Moreover, the RTC services provided 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. For these reasons, 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. 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.