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

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization & coverage for 6 months of residential treatment center (RTC) upon discharge from the acute inpatient level of care (LOC). The American Academy of Child and Adolescent Psychiatry and American Association of Community Psychiatrists 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 CALOCUS-CASII. This instrument provides a reliable framework for determining the appropriate LOC 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, this patient meets the criteria for RTC services for 45 days. For dimension 1, patient has been at extreme risk of harm (score 5) due to verbal and physical aggression toward others, including his younger siblings. The provider noted that the patient has engaged in self-harm behaviors and expressed suicidal ideation with a plan on several occasions stab himself with a knife and overdose on cough drops. The patient hid a knife and then attempted to stab his stepfather when asked to turn it over. The patient has reported command auditory hallucinations to kill his mother, stepfather, and school personnel. The patient has engaged in animal cruelty and fire setting. The records document that the patient has current suicidal and homicidal behavior or such intentions with a plan and valuable means to carry out this behavior, without expressed ambivalence or significant barriers to doing so in presence of command hallucinations or delusions that threaten to override usual impulse control.  For dimension 2, patient has demonstrated serious functional impairment (score 4) given his oppositional, defiant, impulsive, and aggressive behaviors toward others. The patient has required a 1:1 adult supervision at school in order to manage his behaviors. The patients behaviors adversely affect his siblings and his home environment. There is serious disruption of interpersonal interactions with consistent conflict and disrupted interactions with others. There is evidence of serious deterioration of interactions with consistent conflict or otherwise disrupted interactions with others, which may include impulsive or abusive behaviors.  For dimension 3, patient has significant co-occurrence (score 3) considering his diagnoses of ADHD, PTSD & conduct disorder, as well as insomnia. PTSD, ADHD, & depression can adversely affect sleep & conversely, poor sleep can exacerbate symptoms of ADHD, PTSD, & depression. Thus, medical conditions are present that may adversely affect, or be adversely affected by, the presenting condition.  For dimension 4A, patients recovery environment is highly stressful (score 4). The records document that the patients parents are separated, & the patient infrequently sees his biological father, who lives in another state. The patient has shown significant behavioral issues following visits with biological father. His mother reportedly struggles with bipolar disorder. He has behavioral problems at school & requires 1:1 adult supervision. His parents indicate that they have been unable to manage the patients behavioral issues. There is serious disruption of family and social milieu.  For dimension 4B, patients recovery environment provides minimal support (score 4). The provider charted that the patients parents appear supportive of the patient & his school has provided a 1:1 adult supervision during school hours. However, there are serious limitations in the patients access to sources of support to ensure that his emotional needs are met. There is evidence of few community supports and/or serious limitations in access to sources of support so that material, health, and/or emotional needs are mostly unmet.  For dimension 5, patient has shown poor resiliency & response to services (score 4). Prior treatment has included outpatient psychotherapy, psychiatric medications, WRAP services, a partial hospitalization program, & three psychiatric hospitalizations. The patient has demonstrated frequent evidence of innate vulnerability under stress and difficulty resuming progress toward expected developmental level. Overall, previous treatment has not achieved complete remission of symptoms or optimal control of symptoms even with intensive and/or repeated exposure to interventions.  For dimension 6, the patient has exhibited limited engagement in treatment (score 3) due to reports that the patient is guarded and has minimized his symptoms & events that led to his hospitalization. The provider noted that the patient lacks insight. The patient has an ambivalent, avoidant, or distrustful relationship with clinicians & other care providers. These findings give the patient a composite score of 27, which is consistent with Level 5 medically monitored residence-based services. However, per CALOCUS-CASII, the patients scores of 5 for risk of harm supports treatment at Level 6 medically-managed residence-based services. The patient is currently admitted to a Level 6 facility. Once he is sufficiently stabilized & determined to be appropriate for step down to a RTC by his hospital treatment team, a portion of the requested RTC services are medically necessary for the treatment of this patient. Moreover, a portion of the requested RTC services are in accordance with the generally accepted standards of mental health & 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. However, the records do not support that six months of RTC treatment is medically necessary for this patient. Based on CALOCUS-CASII guidelines, 45 days RTC services upon discharge from the acute inpatient LOC is medically necessary. Final Result: The reviewer determined that a portion of the requested services is 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 & 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.