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 provided by Newport Academy. 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, 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 services.With regard to risk of harm, the records support a score of 3. The patient has a significant risk of harm, due to daily cannabis use along with usage of hallucinogens, alcohol, benzodiazepines, and psychedelics. The patient reports a history of putting herself in risky situations. The records note a history of overdosing on alcohol and benzodiazepines within the last year, resulting in inpatient psychiatric hospitalization, and of self-injurious behavior in the form of cutting. The records note that the patient appears to have little insight.In terms of functional status, the records support a score of 4. The documentation noted serious functional impairment due to difficulty with motivation, staying focused, and concentrating at school. The patient was truant from school, failing, and had a record of being suspended. The patient reported being cited for possession with pending legal consequences. With regard to comorbidity, the records support a score of 4. The patient had major comorbidity, due to the presence of psychiatric diagnoses, substance use disorder, and recent substance use. In terms of level of stress of the recovery environment, the records support a score of 4. The patient had a highly stressful environment due to recent deterioration of family relationships. The patient described a poor relationship with and not speaking with her father, and fighting with her mother, on a regular basis. The records noted that the patients parents separated in and disagreed over parenting.  With regard to level of support of the recovery environment, the records support a score of 3 due limitations in the availability of environmental support, as the patient reports her relationship with her mother is good although with regular arguments. The patient reported that her mother was partially supportive of her treatment and that she had no idea if her farther was supportive. In terms of resiliency and treatment history, the records support a score of 3. The patient had moderate resiliency and/or response to treatment due to a history of hospitalization following an overdose with Xanax and alcohol, and a history of outpatient treatment. With regard to treatment acceptance and engagement, the records support a score of 3. The patient does not appear to understand the nature of her behavior and its potential for serious and potentially life-threatening consequences, minimizing and justifying her behavior. Thus, the patient has a total score of 24. The records support a 4 in terms of functional status and comorbidity. 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 provided by Newport Academy were and are medically necessary for the 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 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.