Appeal type: Medical Necessity
Decision: Overturned

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, the patient met the criteria for RTC services provided, with the exception of the dates of non-approved passes. For dimension 1, the patient was at serious risk of harm (score 4) due to a history of disorganized and delusional behavior, impulsivity, and threatening suicide. The patient also has a history of relapsing to substance use shortly after his previous discharges from treatment. The patient engaged in self-harm and property destruction. He assaulted an RTC staff member, and twice eloped within the first month of treatment. He also began refusing medication during his last month of treatment. Overall, the records document an indication or report of significant impulsivity and physical aggression, with poor judgment and insight that were significantly endangering to self or others. For dimension 2, the patient demonstrated moderate functional impairment (score 3) given his refusal to attend school outside of a therapeutic milieu for several months. At the time of admission to the RTC, the patient showed some gains in functioning, but these were only achieved while in the highly structured and supervised program of the previous treatment facility. The patient remained grandiose, and he intermittently struggled with mood dysregulation. The provider noted that the patient struggled with peers during his stay in RTC. This supports that recent gains and stabilization in functioning were achieved while participating in treatment in a structured, protected, and enriched service. For dimension 3, the patient has significant comorbidities (score 3) considering his diagnoses of ADHD, bipolar disorder, anxiety, and substance use disorder. The patient also has a history of multiple concussions, which may contribute to his mental health challenges. Medical conditions are present that may adversely affect, or be adversely affected by, the presenting condition. For dimension 4A, the patients recovery environment was highly stressful (score 4) due to recent deterioration of family relationships as his parents separated several months prior to RTC admission following the patients disclosure of abuse. The patients father is reported to struggle with alcohol abuse, and he was not in contact with the patient. The records establish serious disruption of family milieu due to divorce, conflict, and abuse. For dimension 4B, the patients recovery environment provided limited support (score 3). The provider charted that there were limitations in the patients recovery environment. Although the patients mother was engaged in treatment, the records indicate that patients father has avoided contact with the patient due to allegations of abuse. The patients family had limited ability to respond appropriately to the patients developmental needs and/or problems or was ambivalent toward meeting these needs or addressing these problems. For dimension 5, the patient exhibited poor resiliency and response to treatment (score 4) given his previous inpatient psychiatric hospitalizations and treatment in an RTC for one month. In addition, the patient has participated in a partial hospitalization program (PHP), an intensive outpatient program (IOP), and outpatient treatment. Furthermore, during his most recent stay in RTC, he was hospitalized twice. 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 (score 4) the patient did not appear to understand the severity of his illness and minimized its impact on his functioning. The provider noted that the patient repeatedly refused to comply with medication recommendations and was not consistently engaged in his treatment. The providers describe the patient as defensive and avoidant. The patient also refused his atypical antipsychotic medication during the last month of treatment despite recommendations from his treatment team. The patient had an actively hostile relationship with clinicians and other care providers despite competent efforts to engage with the patient. In addition, the patient actively, frequently disrupted or stonewalled assessment and treatment. 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 score of 4 for risk of harm also supports treatment with Level 5 medically monitored residence-based services. However, the patient eloped from the RTC against the recommendations of his treatment team. Thus, while the patient was away from the RTC services were not medically necessary. For these reasons, a portion of the RTC services were medically necessary for treatment of this patient. Final Result: The reviewer determined that a portion of the services at issue was medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially 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.