Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) services. Findings:  The physician reviewer found that  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 has been at serious risk of harm (score 4), given her suicidal ideation and a history of self-harm and multiple past suicide attempts. The patient has also demonstrated significant impulsivity, poor judgment and insight that are significantly endangering to self or others. The patient endorsed multiple risky behaviors prior to admission, including unsafe sex and drug use. This is also demonstrated by the patients risky behavior while at the RTC, including eloping from the RTC and drinking an entire bottle of Benadryl.  For dimension 2, the patient has demonstrated moderate functional impairment (score 3), due to conflict with parents and frequent school truancy, followed by some gains made in the structured setting of the RTC. Conflicted, withdrawn, or otherwise troubled in relationships with peers, adults, and family, but without episodes of physical aggression. For dimension 3, the patient has significant co-morbidities (score 3) considering the presence of significant mood symptoms as well as substance abuse. Substance abuse is present, with significant adverse effect on functioning and the presenting condition. For dimension 4A, the patients recovery environment has been mildly stressful (score 2). The records document disruptions caused by the pandemic as well as multiple recent school transitions. There has been significant transition requiring adjustment. For dimension 4B, the patients recovery environment is supportive (score 2) due to her parents participation in treatment and treatment planning. Family caretakers are willing and able to participate in treatment if requested to do so and have capacity to effect needed changes. For dimension 5, the patient has exhibited poor resiliency and response to treatment (score 4). The provider noted that the patient continued to use substances and to report significant mood symptoms and impulsive behaviors despite participating in two recent inpatient hospitalizations, a month-long RTC treatment, and IOP treatment in the past four months. 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 has been non-collaborative in treatment (score 4) given her refusal to engage actively in treatment as well as her attempt to elope from the RTC. The patient actively, frequently disrupts or stonewalls assessment and treatment. These findings give the patient a composite score of 22, which is consistent with medically monitored community-based services. Due to a score of 4 on  risk of harm, the patient qualifies for Level 5 medically monitored residence-based services. Per CALOCUS, the patient meets the requirements for Level 5B, intermediate stay medically monitored residence-based services since the patient experiences some suicidal or homicidal ideation with some ambivalence or is highly distressed with some history of harm to self or others. Impulsivity may be present and the risk of engaging in destructive behaviors is significant in an unstructured environment as demonstrated by the patients continued suicidal ideation, impulsivity, and mood changes during residential treatment. Per CALOCUS, typical length of stay at Level 5B is up to 60 days. Given the patients prior failure of a shorter course of RTC level of care, RTC services were and are medically necessary, for up to 60 days from admission forward. Therefore, RTC services were and are medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were and 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.