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 psychiatric 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 meets the criteria for RTC servicesWith regard to risk of harm, the records support a score of 4. The patient had a serious risk of harm, due to a long history of suicidal ideation, numerous past suicide attempts including three overdose attempts, significant self-harm, and impulsive behaviors including running away. The patient endorsed intense urges to self-harm. The patient appeared to not be forthcoming or honest with treatment staff about her suicidality and the records appeared to report a history of suicidal intent directly after the patient denied suicidal ideation to treating providers.In terms of functional status, the records support a score of 3. The documentation noted moderate functional impairment as patient has an IEP and has problems in school secondary to mental health issues. The records note that she is avoidant of social situations, does not have friends, lacks coping skills, and has an inability to form relationships.  With regard to comorbidity, the records support a score of 2. The patient has minor comorbidity, due to the presence of regular cannabis use, insomnia, and medication-induced constipation. In terms of level of stress of the recovery environment, the records support a score of 3. The patient had a mildly stressful environment as the records noted that the patients parents had a contentious divorce, and that she had a strained relationship with her siblings and with her mother. The patient reported that she did not get along with her family members. With regard to level of support of the recovery environment, the records support a score of 3 as the patient does not view her family members as supportive, has a strained relationship with her mother and siblings, and does not have friends. The patients father appeared to be supportive as evidenced by his involvement in her treatment. In terms of resiliency and treatment history, the records support a score of 4. The patient has negligible resiliency and/or response to treatment as prior treatment has included RTC, multiple psychiatric hospitalizations, and numerous psychotropic medications. With regard to treatment acceptance and engagement, the records support a score of 4. The patient has a history of stopping her psychotropic medications and of being resistant to therapy. Thus, the patient has a total score of 23. The records support a 4 in terms of risk of harm. In this case, the recommended level of care is medically monitored residence-based services. With the elevated risk of harm noted, the patient meets CALOCUS 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, psychiatric RTC services were and are 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.