Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement for inpatient behavioral health 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 inpatient behavioral health services. For dimension 1, the patient was at serious risk of harm (score 4) due to recent suicidality and urges to self-harm, as well as substance use. The patient has demonstrated current suicidal ideation with expressed intentions and continued desire to engage in self-harm. For dimension 2, the patient has demonstrated severe functional impairment (score 5) given his inability to attend school regularly and keep up with academic expectations, as a result of mental health symptoms and recent bullying. The patient was attending school sporadically and unable to maintain appropriate school behavior or academic achievement given age and developmental level. For dimension 3, the patient has significant co-morbidity (score 3), due to recent daily alcohol use of which his parents were unaware. Substance use was present, with significant adverse effect on functioning and the presenting condition. For dimension 4A, the patients recovery environment was moderately stressful (score 3) given his school difficulties, recent discharge from the supportive environment of the IOP program, and recent school bullying. The records support disruption of family milieu with serious school difficulties and substance abuse. Moreover, the patient was the subject of ongoing harassment by his peers. For dimension 4B, the patients recovery environment was supportive (score 2) as his parents actively participated in treatment and treatment planning. The patients family 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 has exhibited negligible resiliency and response to treatment (score 5). The records document that the patients symptomatology persisted despite treatment at various levels of care. The patients symptoms were persistent and functional ability showed no significant improvement despite intensive treatment exposure. In addition, developmental pressures and life changes have created sustained turmoil and developmental regression. For dimension 6, the patient was constructive in treatment (score 2) as his providers reported that he actively participated in his treatment plan and he was able to develop a positive relationship with his providers. Just prior to discharge, the patient revealed that he had alcohol and knives hidden in his room at home, which allowed for removal of those items prior to his discharge. This gives the patient a composite score of 24, which is consistent with medically managed residence-based services, such as inpatient behavioral health level of care. This level of care is consistent with CALOCUS, which suggests Level 6, medically managed residence-based services for patients with a score of 5 on functional impairment. In this case, the patient received outpatient therapy and medication management as well as months of IOP services, but continued to experience escalating symptoms and concerning behaviors, including daily alcohol use, irritability and impulsivity, and suicidality and self-harm urges. His parents expressed concern for his safety at home and his outpatient providers agreed that he required a higher level of care. All told, the inpatient behavioral health services were medically necessary for this patient. 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.