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 any or all of the residential treatment center (RTC) level of care. 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, this patient meets the criteria for RTC services.With regard to risk of harm, the records support a score of 4. The patient had a serious risk of harm, due to a history of repeated suicide attempts, suicidal ideation, and self-harm. The patient endorses passive suicidal ideation. She has a history of daily substance use prior to admission and exhibits little to no genuine inclination to reduce or stop her substance use. She is impulsive, reactive, and exhibits little insight and poor judgment. In terms of functional status, the records support a score of 4. The documentation noted serious functional impairment due to an inability to meet age-appropriate expectations and fulfill responsibilities outside of a highly structured and supportive environment. The patient struggles to manage her anger appropriately, even in the treatment setting, and is quick to become verbally aggressive to staff when she does not get her way or disagrees with rules and policies. She has poor relationships with peers outside of the supported setting of RTC. With regard to comorbidity, the records support a score of 3. The patient had significant comorbidity, due to the presence of depression and co-occurring substance use disorders. She endorses ongoing cravings to use and reports trouble sleeping. 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 ongoing conflict with her father, whose involvement in her life has fluctuated. She reports not getting along with her step-parent. She has had three friends die in the past year and her only other friendship is marked by excessive dependency.  With regard to level of support of the recovery environment, the records support a score of 3. He patient reports feeling invalidated by her mother and not wanting to disclose anything to her for fear of making her cry or hurting her feelings. She reports that her home environment is not especially supportive, and that she has one friend with whom she has a co-dependent relationship. 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  prior treatment has included outpatient therapy and psychiatric hospitalization. She has also been in her current residential treatment placement for about ten weeks with insufficient progress. With regard to treatment acceptance and engagement, the records support a score of 4. The patient is conflicted about and minimizes her need for treatment. She is resistant to exploring certain issues in therapy, minimizes her substance use, and blames others for her lack of progress. The patients engagement was minimal as she does not appear to accept age-appropriate responsibility for her role in the development, perpetuation, or consequences of her problems.  Thus, the patient has a total score of 25. The records support a 4 in terms of risk of harm and of  functional status. In this case, the recommended level of care is medically monitored residence-based services. With the functional impairment and elevated risk of harm noted, the patient meets Level 5b extended stay criteria.  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 level of care was and is 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 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.