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

Nature of Statutory Criteria/Case Summary: The patients parent has requested 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 does not meet the criteria for RTC services.With regard to risk of harm, the records support a score of 2. The patient has some risk of harm, due to a recent physical altercation during which he pushed his stepfather, and the police were called. The patient does not endorse suicidal ideation and does not have a history of suicide attempts or self-harm behaviors.In terms of functional status, the records support a score of 3. The documentation noted moderate functional impairment due to a conflictual relationship with his mother which appears to be a result, in part, of his continued engagement in eating disordered behaviors. The patient attends school, is employed, and is planning to attend college away from home.With regard to comorbidity, the records support a score of 3. The patient had significant comorbidity, due to the presence of an eating disorder, placing him at risk of malnutrition, vital sign instability, electrolyte disturbances, and cardiac abnormalities, along with psychiatric issues and constipation. Mood and anxiety symptoms can exacerbate eating disorder behaviors and conversely, malnutrition and eating disordered behaviors can exacerbate mood symptoms 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 a somewhat difficult relationship with his mother, with communication difficulties. The records note that family tensions have remained quite high.With regard to level of support of the recovery environment, the records support a score of 3 as the patients mother is supportive of his treatment but reports feeling at a loss on how to best support the patient.  In terms of resiliency and treatment history, the records support a score of 4. The patient has poor response to treatment and recovery management as the patient continued to struggle with binging and purging despite prior treatment including outpatient treatment, an eating disorder IOP, two eating disorder PHPs, residential treatment for eating disorder. The patient has been able to gradually gain weight.With regard to treatment acceptance and engagement, the records support a score of 3. The patients engagement with his eating disorder treatment plan is noted as fair. The patients mother reports concern that the patient is not truthful with his treatment providers. While the patient engages with his gender therapist, he has not followed through on finding an eating disorder therapist. Thus, the patient has a total score of 21. In this case, the recommended level of care is medically monitored community-based services. This is inconsistent with RTC level of care. In this patients case, RTC level of care is not in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the requested services are not clinically appropriate in terms of type, frequency, extent, site, and duration. Therefore, RTC services are not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested services is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.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.