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 of Community Psychiatrists (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 provides a reliable framework for determining the appropriate level of care for adolescents needing mental health treatment. 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) developmental, medical, substance use and psychiatric comorbidity; (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, the patient meets the criteria for RTC services. For dimension 1, the patient has been at serious risk of harm (score 4) due to attempted suicide on at least two occasions. The patient has been engaging in increasingly risky behaviors such as taking substances and alcohol together in the hopes that she will get high and die. She has wandered alone at night while under the influence of drugs and alcohol. She has hit her head multiple times while under the influence of drugs and alcohol. The patient is described as impulsive and engages in high risk behaviors including using various types of drugs, using alcohol, and having sex with multiple partners. Although patient reports that her suicidal ideation has improved, she remains intermittently suicidal. There is indication or report of significant impulsivity with poor judgment and insight that is significantly endangering to self or others. For dimension 2, the patient has demonstrated serious functional impairment (score 4) given her physical aggression and fights at school in the recent past. The patient also has a history of being in juvenile detention after stealing her mothers vehicle. Previously a good student, the patient is close to failing all of her classes and she reports that she has engaged in substance use on school premises. The records document serious deterioration of interpersonal interactions with consistent conflict or otherwise disrupted interactions with others, which may include impulsive or abusive behaviors. For dimension 3, the patient has major co-occurrence of conditions (score 4) as evidenced by her history of attention-deficit/hyperactivity disorder (ADHD), eating disorder, and substance use disorders. The patient has sustained multiple concussions with post-concussive sequelae, which can contribute to mood lability. The patients eating disorder places her at risk of malnutrition and other comorbidities. The patients mood and anxiety symptoms can exacerbate eating disorder behaviors and conversely, malnutrition and eating disordered behaviors can exacerbate mood symptoms and anxiety. Furthermore, the patients substance use is uncontrolled and likely contribute to her mood instability and depression. Medical conditions are present that will adversely affect, or be affected by, the presenting condition. For dimension 4A, the patients recovery environment has been highly stressful (score 4). The provider noted that there have been a number of stressors in the patients life including the death of a friend by suicide, suicide attempt of her cousin, her older brother moving away, and the death of several extended family members over the last few years. The patient also sustained a concussion and experienced post-concussive sequelae. The patient is failing her classes in school, and she has shown difficulty avoiding exposure to substance use and its effects. There is documentation of serious disruption of family and social milieu as well as difficulty avoiding exposure to substance use and its effects. For dimension 4B, the patients recovery environment has provided limited support (score 3) since the patient identifies her brother as a source of support, but he recently moved away. The patient has few friends and does not confide in them. The patients family has limited ability to respond appropriately to the patients developmental needs and problems or is ambivalent toward meeting these needs or addressing these problems. For dimension 5, the patient has shown moderate or equivocal resiliency and response to services (score 3). The provider noted that prior treatment has included outpatient psychotherapy for several years and psychiatric medication management. The patient has demonstrated inconsistent or equivocal capacity to deal with stressors and maintain normal development. For dimension 6, the patient has exhibited adequate response to services (score 2) given the patients appearance of participation in treatment as noted by the providers. The patient is noted to be able to develop a trusting, positive relationship with clinicians and other care providers. These findings give the patient a composite score of 24, which is consistent with Level 5 medically monitored residence-based services. Per CALOCUS-CASII, the patients scores of 4 for risk of harm, functional status, and co-occurrence also supports treatment at Level 5. Moreover, the RTC services were and are in accordance with the generally accepted standards of mental health and substance use disorder care, clinically appropriate in terms of type, frequency, extent, site, and duration, and not primarily for the convenience of the patient or provider. For these reasons, RTC services were and are medically necessary for 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 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.