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

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for family therapy once per week and/or individual therapy services twice per week, or in the alternative, individual therapy services once per week. 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, the patient meets the criteria for high intensity community-based services, which can take many forms and service delivery occurs two or more days per week and can include individual therapy services twice weekly and family therapy once weekly.For dimension 1, the patient has been at some risk of harm (score 3) due to their history of suicide attempt and polysubstance use. The provider noted that the patient struggles with impulsivity. The patient denies current suicidal ideation. The records document no active suicidal ideation, but a history of suicidal behavior. For dimension 2, the patient has demonstrated moderate functional impairment (score 3) given their reports of continued symptoms of depression and post-traumatic stress disorder (PTSD). The patient continues to struggle with focus, concentration, impulsivity, and procrastination. They are attending online school. Recent gains in functioning appear to have been achieved while participating in treatment in a structured and protected environment. For dimension 3, the patient has significant co-occurrence (score 3) given their diagnosis of attention-deficit/hyperactivity disorder (ADHD), which is neurodevelopmental disorder, in addition to depression, anxiety, and PTSD. The patient also has a history of polysubstance use disorder, currently in early remission. There is evidence of a developmental disability present that may adversely affect the presenting condition, and/or may require significant augmentation or alteration of treatment for the presenting condition or co-morbid condition, or adversely affects the presenting condition. For dimension 4A, the patients recovery environment has been moderately stressful (score 3). The provider noted that the patient has a history of sexual abuse by a male relative until the age of 15. The patient struggles with low self-esteem and challenging peer relationships. There is documentation of disruption of family and social milieu. For dimension 4B, the patients recovery environment provides limited support (score 3) due to limited availability to outpatient therapy services. The records indicate that the patients mother advocates for the patients treatment. Overall, community resources only partially compensate for unmet material and emotional needs and the patient has limited or inconsistent access to network. For dimension 5, the patient has exhibited moderate or equivocal resiliency and response to treatment (score 3). The provider noted that prior treatment has included limited outpatient treatment, psychotropic medications, partial hospitalization program (PHP), residential treatment center (RTC), and inpatient psychiatric hospitalization. The records document that 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 has shown adequate engagement in services (score 2) based on the available documentation from the patients providers. The patient has been able to develop a trusting, positive relationship with clinicians and other care providers. These findings give the patient a composite score of 20, which is consistent with Level 3 high intensity community-based services. Per CALOCUS-CASII, clinical services at Level 3  include more than one type of therapy service and service delivery occurs two or more days per week. Moreover, the requested family therapy and individual therapy services 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. All told, the requested family therapy once per week and individual therapy services twice per week are medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested services 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.