Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for 45-day RTC program for teens ages 13-17 that provides three or more individual sessions per week with a licensed clinician, two family sessions per week with a licensed clinician, assessment and medication management by a Board Certified adolescent psychiatrist as needed, group therapy, and weekly psychoeducation and process group. Findings:  The physician reviewer found that 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 a 45-day RTC program for teens ages 13-17 that provides three or more individual sessions per week with a licensed clinician, two family sessions per week with a licensed clinician, assessment and medication management by a Board Certified adolescent psychiatrist as needed, group therapy, and weekly psychoeducation and process group. For dimension 1, the patient has been at serious risk of harm (score 4) due to indication or report of significant impulsivity with poor judgment and insight that are significantly endangering to self or others. This is demonstrated by the patients repeated suicide attempts and threats of suicide. For dimension 2, the patient has demonstrated moderate functional impairment (score 3) given her troubled relationships with both parents. There is documentation of conflicted, withdrawn, or otherwise troubled relationships with peers and family but without episodes of physical aggression. For dimension 3, the patient has no co-morbidities (score 1). The records do not report evidence of medical illness, substance use, or developmental disorders affecting mental health. For dimension 4A, the patients recovery environment is moderately stressful (score 3) due to estrangement from her mother due to mother's lack of acceptance of the patients gender identity. This supports disruption of family milieu with absence of parental support. For dimension 4B, the patients recovery environment provides limited support (score 3) considering her parents difficulties in accepting the patients gender identity and in ensuring that the patient participates in outpatient treatment visits. The patients family has limited ability to respond appropriately to the patients problems and is ambivalent toward meeting these needs or addressing these problems. For dimension 5, the patient has exhibited poor resiliency and response to treatment (score 4). The records document developmental pressures and life changes have created episodes of turmoil or sustained distress, as evidenced by the patients multiple recent hospitalizations for suicidality. 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 patients parents have been non-collaborative (score 4) due to inconsistent engagement with treatment, including missed appointments and inconsistent medication adherence. The patients parents have been able to accept the patients need to change but have been unable or unwilling to consider the need for any changes in other family members. These findings give the patient a composite score of 22, which is consistent with medically monitored community-based services. Per CALOCUS, the patients score of 4 on risk of harm supports treatment at Level 5 medically monitored residence-based services. Furthermore, the patient qualifies for Level 5B intermediate stay medically monitored residence-based services, since the patient is highly distressed with some history of harm to self or others, as demonstrated by the patients multiple suicide attempts and recent suicidality. Moreover, the patients family has difficulty responding to the patients needs appropriately, as demonstrated by parents struggles to accept and support the patient in his gender identity, and to adhere to outpatient treatment recommendations. Per CALOCUS, the typical length of stay at Level 5B is up to 60 days. In this case, the patient and his family have demonstrated difficulty adhering to outpatient care. The patients repeated recent suicide attempts, recurring suicidal ideation, and psychiatric hospitalizations indicate that attempts at outpatient treatment were not effective. For these reasons, the requested 45-day RTC program for teens ages 13-17 that provides three or more individual sessions per week with a licensed clinician, two family sessions per week with a licensed clinician, assessment and medication management by a Board Certified adolescent psychiatrist as needed, group therapy, and weekly psychoeducation and process group, is medically necessary for treatment of this patient.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.