Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for wilderness program services.The Child and Adolescent Level of Care Utilization System (CALOCUS) provides a reliable framework for determining the clinically appropriate level of care for a child or adolescent in 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 (Astressors, and B-supports); (5) resiliency and treatment history; and (6) treatment acceptance and engagement. The composite score is then used to determine the level of care needed.For dimension 1- Risk of Harm. This dimension assesses potential for harm to self or others, or having harm inflicted upon them. The records note that the patient had a history of two past suicide attempts by overdose, both of which resulted in medical and psychiatric hospitalization. In addition, records describe a history of suicidal ideation with near follow-through of her plans (fashioning a noose to hang herself after barricading herself in a bathroom while in residential treatment) which was prevented when staff interrupted her attempt, multiple acts of self-injurious behaviors (cutting), and acts of aggression to others. Furthermore, the patient had a history of repeatedly engaging in acutely self-endangering behaviors (stealing a car, using illicit drugs). [Score 5  Extreme Risk of Harm]For dimension 2  Functional Status. This dimension assesses the degree to which a person is able to fulfill responsibilities for a given age level. The records describe the patient as repeatedly irate and argumentative with parents, refusing to comply with parental expectations or limits. The records also describe disruptive and dangerous behaviors at school including passing alcohol to peers, stealing resulting in school suspension, skipping school and sports practice, stealing a car, and an inability to attend school for any significant length of time due to repeated hospitalizations and residential treatment stays. [Score 5  Severe Functional Impairment]For dimension 3  Comorbidity. This dimension assesses the co-existence of disorders across four domains (psychiatric, substance use, medical or developmental) that may complicate the course of treatment. The patient was reported to use alcohol and marijuana but her use had been limited due to repeated stays in treatment facilities. The patients depression and anxiety were present and impaired her functioning (both inside and outside of treatment facilities) and were persistent even in the absence of stressors consistent with major comorbidity. In addition, the patient suffered from insomnia, which adversely affected her mood and ability to manage stressors. Perhaps most importantly, the patient had suffered a sports-related concussion, after which time her mood, behavior and functioning precipitously declined. [Score 4  Major Co-Morbidity]For Recovery Environment dimension 4A- Stress. This dimension assesses the stressors in the environment, social circumstances, and interpersonal relationships. The patients recovery environment was highly stressful due to significant conflict between her and her parents, her history of trauma resulting from a social media post and sexual assault, as well as serious disruption to her social milieu stemming from a social media post which was then widely disseminated by another peer, leading to death threats, significant alienation and marginalization from her peer group. [Score 4  Highly Stressful Environment]For Recovery Environment dimension 4B- Support. This dimension assesses the presence of family and social support to augment the recovery environment. The patients recovery environment appeared to be generally supportive, although parental capacity to effect needed changes appeared to be somewhat impaired as evidenced by their difficulty following through on the treatment recommendations of at least one treatment facility. [Score 2  Supportive Environment]For dimension 5- Treatment and Recovery History. This dimension assesses success or failure to make use of treatment and natural support that fosters resilience. The patient had shown poor response to treatment. Records describe the patient as superficial, guarded, avoidant, angry, and blaming of others. The patients numerous treatment records reveal persistent symptomatology with minimal response to extensive treatment. [Score 5 - Negligible Resiliency and/or Response to Treatment]For dimension 6  Engagement. This dimension assesses a persons understanding of their illness and treatment, and their ability and willingness to engage in the treatment process. The patient consistently struggled to engage with providers despite their best efforts to engage with her. Records consistently describe an inability or unwillingness to accept responsibility for her role in the development and perpetuation of her problems and the consequences of the patients choices/actions. [Score 4  Non-Collaborative]These findings give the patient a composite CALOCUS score of 29, which is consistent with Level 6: Medically Managed Residence-Based Services. The patients scores of 5 in Risk of Harm and Functional Status dimensions also automatically qualify the patient for Level 6 services. Accordingly, the wilderness program services at issue were medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the services at issue were medically necessary to treat the patient's 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.