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. 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 level of care services. For dimension 1, the patient has been at serious risk of harm (score 4) due to report of significant impulsivity with poor judgment and insight that is significantly endangering to himself or others. The patient discussed stealing in order to procure drugs. In addition, there are signs of consistent of deficits in the patients ability to care for himself and use the environment for safety as evidenced by the recent 17-pound weight loss. Moreover, the patient demonstrated a recent pattern of excessive substance use resulting in clearly harmful behaviors with no demonstrated ability of the patient or family to restrict use. For dimension 2, the patient has demonstrated serious functional impairment (score 4) given his serious deterioration of interpersonal interactions with consistent conflict or otherwise disrupted interactions with others, which includes impulsive behaviors, as evidenced by the patients conflict with his parents. The patient has also been unable to adequately perform in a specialized school setting. In addition to his truancy and academic struggles prior to admission to the RTC, the patient continued to exhibit academic struggles while enrolled in the RTC. For dimension 3, the patient has significant comorbidities (score 3) since the patients recent substance use that has significant impact on the presenting condition has been arrested due to use of a highly structured or protected setting. The patient endorsed cravings for cannabis, but he was excited and prepared for his session. For dimension 4A, the patients recovery environment is mildly stressful (score 2) due to recent conflict with his parents and sister, as well as academic pressures. The patients expectations for performance at home and school create discomfort. For dimension 4B, the patients recovery environment is supportive (score 2) given his parents engagement with treatment and treatment planning. The patients family 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 moderate resiliency and response to treatment (score 3). The records document that the patient has shown limited response to outpatient care and a lack of participation in outpatient treatment. However, the patient has increased his participation since admission to the RTC level of care. The patients previous experience in treatment at low level of intensity was not successful in relief of his symptoms or optimal control of symptoms. For dimension 6, the patient has been incompletely engaged (score 3) due to his minimization of the seriousness of his substance abuse and ambivalence about fully engaging in the treatment process at the RTC. The patient minimizes distressing behaviors and consequences. These findings give the patient a composite score of 21, which is consistent with medically monitored community based services. Per CALOCUS, the patients scores of 4 on risk of harm and functional impairment support treatment at Level 5, medically monitored residence based services. Furthermore, the patient qualifies for Level 5B, intermediate stay medically monitored residence based services considering his recent conflict with his parents and sister, academic struggles, recent cessation of substance use due to the highly structured and protected setting of the RTC, lack of response to lower levels of care, and the patients ambivalence about treatment. Per CALOCUS, the length of stay usually does not exceed 60 days at this level of care. However, the provider noted that the patient is making progress in RTC, but is still ambivalent about treatment and problematic behaviors, such as stealing and inappropriate sexual behaviors. Therefore, the patient qualifies for continued RTC for two months from this evaluation. This will minimize the risk of deterioration and relapse upon discharge from the RTC, and allow the patient and his parents to continue working on treatment goals in a structured setting without access to substances. Given these findings, the 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.