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 weekly intensive behavioral therapy services. Findings:  The physician reviewer found that American Academy of Child and Adolescent Psychiatry (AACAP) and American Association of Community Psychiatrists (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 provides a reliable framework for determining the appropriate level of care 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 weekly intensive behavioral therapy services. For dimension 1, the patient has been at significant risk of harm (score 3). The records document that the patient has experienced incidents of acting without thinking, and physically endangering others, including other children at school, and being assaultive toward his mother at home. There is indication or report of incidents of acting without thinking, and physically aggressive actions that endanger self and others. For dimension 2, the patient has demonstrated moderate functional impairment (score 3) due to deficits in interpersonal relationships, including conflictual relationships at school and at home. However, there is documentation that the patient has been able to still maintain adequate academic performance and have socially constructive relationships, such as with his provider. There is documentation of chronic and/or variably severe deficits in interpersonal relationships, but with ability to engage in socially constructive activities, and ability to maintain responsibilities. For dimension 3, the patient has no co-occurrence (score 1). There is no evidence of medical illness, substance abuse, developmental disability, or psychiatric disturbances apart from the presenting condition. For dimension 4A, the patients recovery environment has been moderately stressful (score 3). There is documentation that the patients mother has difficulty meeting the patients needs due to her own limited insight and frustrations, as well as work obligations. The patient does not have a relationship with his father. The records support disruption of family milieu. For dimension 4B, the patients recovery environment provides limited support (score 3). Per the provider, the patients mother appears to have limited ability to respond appropriately to the patients developmental needs and/or problems or is ambivalent toward meeting these needs or addressing these problems. The provider noted that the patients mother is highly stressed with little insight into the patients needs. The patient has reported that his mother frequently yells at him. For dimension 5, the patient has exhibited moderate or equivocal resiliency and response to services (score 3). Overall, the patient has demonstrated an inconsistent or equivocal capacity to deal with stressors and maintain development. The patients treatment at low level of intensity has not been successful in relief of symptoms or optimal control of symptoms. For dimension 6, the patients parent has shown minimal engagement (score 4) due to his mothers difficult and unproductive relationship with clinicians and other care providers. The provider charted that the patients parent has been unable to reach shared definition of the development, perpetuation, or consequences of problem. These findings give the patient a composite score of 20, which is consistent with medically monitored community-based services: intensive integrated services without 24-hour psychiatric monitoring. This level of care also includes the requested weekly intensive behavior therapy services. Moreover, the requested weekly intensive behavioral 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 are not primarily for the convenience of the patient or provider. All told, the weekly intensive behavioral therapy services 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.