Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

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 (AACAP) and American Association for Community Psychiatry (AACP) have unified the Child and Adolescent Level of Care Utilization System (CALOCUS) and the Child and Adolescent Service Intensity Instrument (CASII) into a single instrument, the Child and Adolescent Level of Care/Service Intensity Utilization System (CALOCUS-CASII). This instrument is a standardized tool used to determine the intensity of services needed for children and adolescents, 6-18 years of age, presenting with psychiatric, substance use, medical and/or developmental concerns. Using CALOCUS-CASII, 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) co-occurrence of developmental, medical, substance use and psychiatric conditions; (4) recovery environment (a. stressors and b. supports); (5) resiliency and response to services; and (6) engagement. The composite score is then used to determine the level of care needed. Applying the CALOCUS-CASII framework, this patient meets the criteria for RTC servicesWith regard to risk of harm, the records support a score of 4. The patient had a serious risk of harm. The patient urges to self-harm. In notes, the patient reported that she would try to overdose if she went home. The records noted an episode at the RTC when the patient became agitated and punched a hole in a wall. In terms of functional status, the records support a score of 4. The documentation noted serious functional impairment as the patient has been receiving intensive mental health treatment at IOP, PHP, RTC, and inpatient hospitalization levels of care. With regard to comorbidity, the records support a score of 3. The patient had significant comorbidity, due to the presence of fibromyalgia. Anxiety and depression may exacerbate symptoms of fibromyalgia and individuals with fibromyalgia often experience depression and anxiety. In terms of level of stress of the recovery environment, the records support a score of 3. The patient had a moderately stressful environment due to the patient reporting that she does not have a good relationship with her father, describing him as verbally abusive. With regard to level of support of the recovery environment, the records support a score of 3. While the patients mother and sister are noted as supportive, the patients father reported not supporting the patients taking medication. In terms of resiliency and treatment history, the records support a score of 4. The patient had poor response to treatment and recovery management as her symptoms have persisted despite treatment attempts at various levels of care including IOP, PHP, RTC, and inpatient hospitalization. With regard to treatment acceptance and engagement, the records support a score of 2. The patient has been participating in her treatment and is compliant with medications.  Thus, the patient has a total score of 23. The records support a 4 in terms of risk of harm and functional status. In this case, the recommended level of care is medically monitored residence-based services. This is consistent with the level of care that the patient was and is receiving at the RTC. In this patients case, RTC level of care was and is in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the services at issue were and are clinically appropriate in terms of type, frequency, extent, site, and duration. The services at issue were not and are not primarily for the economic benefit of the health care service plan and subscribers or for the convenience of the patient, treating physician, or other health care provider. Therefore, RTC services  were and are medically necessary for the treatment of 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 sub-specialty 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.