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

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement for residential treatment center (RTC) services. Findings:  The physician reviewer found that 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, the patient met the criteria for RTC services.For dimension 1, the patient was at serious risk of harm (score 4) due to a history of verbal and physical aggression, as well as property destruction. The records indicate that the police have been called to the home on at least two occasions and the patient has required evaluation in the emergency department on four separate occasions due to his behavior. The patient has also engaged in self-injurious behaviors and he endorsed passive suicidal ideation. There is a history of impulsivity. During the period under review, the patient perpetrated two physical altercations. There is evidence of current suicidal ideation with either clear, expressed intentions and/or a history of carrying out such behavior. There was also indication or report of significant impulsivity and physical aggression. For dimension 2, the patient demonstrated serious functional impairment (score 4) given the reported struggles to get along with peers and during the period under review, engaged in physical violence. As a result of the patients repeated aggression, he was discharged from the residential facility. The patient is noted to bully others and not get along with his family members. There was 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 showed significant co-occurrence (score 3). The records document a history of several neurodevelopmental disorders including autism, ADHD, and learning disorder in addition to mental health diagnoses of depression and anxiety. The patients neurodevelopmental disorders likely contributed to his ongoing problems getting along with others and his lack of social success undoubtedly contributes to his depression and anxiety. The patients developmental disability is present that may adversely affect the presenting condition and may have required significant augmentation or alteration of treatment for the presenting condition or co-morbid condition, or adversely affected the presenting condition. For dimension 4A, the patients recovery environment was moderately stressful (score 3) given the patients struggles with meeting expectations as evidenced by his inability to follow the RTC rules regarding aggression. The patient also demonstrated difficulty maintaining safe behavior at the home as evidenced by the need for police intervention on several occasions. The patient struggled to get along with his family members. This suggests that the role expectations exceeded the patients capacity given his age, status, and developmental level. For dimension 4B, the patients recovery environment was supportive (score 2). The records provided limited information about patients parental support, but based on parental advocacy for residential treatment, the patients parents appeared supportive. The patients family caretakers were willing and able to participate in treatment material if requested to do so and had capacity to effect needed changes. For dimension 5, the patient exhibited moderate resiliency and response to services (score 3). The provider noted that prior treatment has included psychiatric care, psychotropic medication, a neuropsychological evaluation, and several emergency department visits. Thus, previous experience in treatment at low level of intensity has not been successful in relief of symptoms or optimal control of symptoms. For dimension 6, the patient demonstrated limited engagement in services (score 3) due to the patients lack of full engagement in treatment as evidenced by his disregard of rules and guidelines of the RTC. The patient attempted to manipulate his parents into removing him from RTC. The patient exhibited limited insight. However, he was also noted to attempt to participate in groups and work towards his treatment goals. The patient was ambivalent, avoidant, or distrustful relationship with clinicians and other care providers.These findings give the patient a composite score of 22, which is consistent with Level 4 medically monitored community-based services. In addition, per CALOCUS-CASII, the patients scores of 4 for risk of harm and functional status supports treatment at Level 5 medically monitored residence-based services. Moreover, the RTC services were 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, the RTC services were 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 subspecialty certification in 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.