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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for therapy services (including one hour, weekly, in-person, individual therapy; one hour, weekly, in-person, family therapy; one hour, weekly, in-person, parent therapy; and one hour, weekly, 1:1 skills coaching). 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 High Intensity Community-Based Services.With regard to dimension 1, risk of harm, the records support a score of 2.  This dimension assesses potential for harm to self or others, or having harm inflicted upon them. The patient has a history of suicidal ideation for which he was seen in the emergency department earlier in the calendar year. He does not have a history of prior suicide attempts. In terms of dimension 2, functional status, the records support a score of 3. This dimension assesses the degree to which a person is able to fulfill responsibilities within developmental constraints. The patient exhibits moderate functional impairment as evidenced by isolative behaviors and increased family discord due to his anxieties around academic performance. His grades have declined. He reports a lack of motivation. His outpatient therapist also reports a progressive decline in his progress since starting this academic year. With regard to dimension 3, co-occurring developmental, medical, substance use and psychiatric conditions, the records support a score of 2. 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 has acne, pectus excavatum, curvature of the spine, and hearing loss. He wears a hearing aid. In terms of level of stress of the recovery environment, the records support a score of 3. This dimension assesses the stressors in the environment, social circumstances, and interpersonal relationships. The patients recovery environment appears moderately stressful. There is family discord and academic stress. With regard to level of support in the recovery environment, the records support a score of 2. This dimension assesses the presence of family and social support to augment the recovery environment. The patients recovery environment appears to be supportive. Her parents attend therapy sessions when necessary and appear to be strong advocates for the patient.In terms of resiliency and response to services, the records support a score of 3. This dimension assesses how past experiences with treatment and recovery might indicate how the patient might respond in the future. Previous treatment has included outpatient individual psychotherapy, psychiatric medication, an intensive outpatient program (briefly  discontinued by the patient due to virtual nature not being helpful), and a partial hospitalization program. Records indicate that the patients outpatient psychotherapist reported, The patient had made good gains in symptom management. He has also been seen in the emergency department for suicidal ideation. With regard to engagement of the patient, the records support a score of 2. This assesses the ability to form therapeutic relationships within developmental constraints. The patient appears to be adequately engaged in treatment.  These findings give the patient a composite score of 17, which is consistent with Level 3 High Intensity Community-Based Services. The records services are in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the requested services are clinically appropriate in terms of type, frequency, extent, site, and duration. The requested services 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, the requested therapy services (including one hour, weekly, in-person, individual therapy; one hour, weekly, in-person, family therapy; one hour, weekly, in-person, parent therapy; and one hour, weekly, 1:1 skills coaching) are medically for the treatment of this patient.Final Result: The reviewer determined that the requested services are medically necessary for evaluation 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.