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 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 met the criteria for RTC services. For dimension 1, the patient was at significant risk of harm (score 3), due to current passive suicidal ideation and a history of a recent suicide attempt. Also, she engaged in self-harm in the protected setting of the RTC. Significant current suicidal ideation with some intent and plan, with an ability for the patient to contract for safety and carry out a safety plan. The patient expressed some reason not to carry out such behavior. For dimension 2, the patient demonstrated serious functional impairment (score 4) given her extreme social withdrawal, lack of close friends, and inability to pass her classes secondary to her mental health symptoms. Significant withdrawal and avoidance of almost all social interaction. For dimension 3, the patient has no comorbidities (score 1) without any history of substance abuse, developmental, or medical conditions adversely affecting patients mental health. No evidence of medical illness, substance abuse, developmental disability, or psychiatric disturbances apart from the presenting condition. For dimension 4A, the patients recovery environment was mildly stressful (score 2), considering her family conflict 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 was supportive (score 2). The provider noted that both of the patients parents were involved in treatment and treatment planning. Family caretakers were willing and able to participate in treatment if requested to do so and have capacity to effect needed changes. For dimension 5, the patient exhibited poor resiliency and response to treatment (score 4), due to persistence of suicidal ideation and disordered eating as well as mood and anxiety symptoms after two inpatient hospitalizations, IOP, and long-term psychotherapy. 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 incompletely engaged in treatment (score 3) given her lack of motivation for treatment. Frequently misses or is late for treatment appointments and is not invested in treatment, including medication and homework assignments. These findings give the patient a composite score of 19, which is consistent with high intensity community-based services. Per CALOCUS, the patients score on functional status met the criteria for Level 5, medically monitored residence-based services. Furthermore, the patient qualified for Level 5B, intermediate stay, medically monitored residence-based services since she experienced suicidal or homicidal ideation with some ambivalence and was she highly distressed with some history of harm to self or others. Per CALOCUS, the length of stay at Level 5B usually does not exceed 60 days. The patient remained at the RTC for less than 30 days, which was within the CALOCUS guidelines. For these reasons, the RTC services were medically necessary for treatment of this patients condition and 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 were not for the convenience of the patient or provider. 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.