Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer  
 
The patient is a 16-year-old non-binary individual with a history of attention-deficit/hyperactivity 
disorder (ADHD), autism spectrum disorder, major depressive disorder with psychotic features, 
generalized anxiety disorder, obsessive-compulsive disorder, suicidal ideation, and self-harm 
behaviors. The Health Insurer has denied the patients residential treatment level of care 
provided from 9/3/21 through 9/8/22 as not medically necessary for the treatment of the 
patients medical condition. The physician reviewer found that (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 did not meet the criteria for the 
residential treatment level of care provided from 9/3/21 through 9/8/22. For dimension 1, the 
patient was at some risk of harm (score 2), as the patient had mild suicidal ideation with no intent 
or conscious plan and with no past history. The records provided for review reflect that the 
patient presented with a history of self-harm and suicidal ideation but no suicide attempts. The 
records reflect that during their stay at RTC, the patient endorsed suicidal ideation but had no 
plan or desire to act on those thoughts. There is also no indication that the patient self-harmed 
during their stay at RTC. For dimension 2, the patient demonstrated moderate  functional 
impairment (score 3). The records reflect that during the patients stay at RTC, there were no 
issues with the patients eating, sleep, or hygiene. The patient was compliant in the classroom 
and participated appropriately in the program. Overall, recent gains and/or stabilization were 
achieved while participating in treatment in a structured, protected, and/or enriched service. For 
dimension 3, the patient had significant co-occurrences (score 3). The patient presented with 
neurodevelopmental disorders, including autism and ADHD, in addition to their psychiatric 
disorders. Overall, a developmental disability was present that adversely affected the presenting 
condition and required significant augmentation or alteration of treatment for the presenting 
condition or co-morbid condition. For dimension 4A, the patients recovery environment was 
moderately stressful (score 3). The patient experienced a disruption of family and social milieu 
as their parents divorced when the patient was two years of age. The patient reportedly struggled 
in their relationship with their father, as he was more authoritarian and had difficulty accepting 
the patients gender identity. The patient struggled with peer relationships but was increasingly 
able to navigate social situations with support. In addition, the records reflect that the patients 
role expectations exceeded their capacity given their age, status, and developmental level. For 
dimension 4B, the patients recovery environment was supportive (score 2). The patients parents 
were supportive of the patients treatment as evidenced by their participation in treatment and 
receptiveness  to  therapist  feedback.  Overall,  the  patients  family  was  willing  and  able  to 
participate in treatment if requested to do so and had the capacity to effect needed changes. For  dimension 5, the patient showed poor resiliency and response to services (score 4), as previous 
treatment did not achieve complete remission of symptoms or optimal control of symptoms even 
with intensive and/or repeated exposure to interventions. The records reflect that the patients 
prior treatment included outpatient psychotherapy, psychiatric treatment including multiple 
psychotropic medications, a partial hospital program, and inpatient psychiatric hospitalization, 
all without significant benefit. For dimension 6, the patient exhibited adequate engagement in 
services (score 2), as the patient passively cooperated in treatment planning and services. The 
records reflect that the patient acknowledged the need for treatment, engaged in treatment, and 
was compliant with medications. These findings give the patient a composite score of 19, which 
is consistent with Level 4 High Intensity Community-Based Services. Therefore, the residential 
treatment level of care provided from 9/3/21 through 9/8/22 was not medically necessary for 
the treatment of this patient.