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

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement for (1) residential treatment center (RTC) services the patient received from Huntsman Mental Health Institute at the University of Utah, and (2) the partial hospitalization program (PHP)  services the patient received from Ascend Healthcare. Findings:  The physician reviewer found that 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 met the criteria for RTC services.With regard to risk of harm, the records support a score of 4. The patient had a serious risk of harm, due to a history of suicidal ideation with a plan, a prior suicide attempt, and a history of self-harm. The records noted that the patient was physically aggressive toward her mother. While at the RTC, the patient continued to struggle with suicidal ideation and self-harm urges. In terms of resiliency and treatment history, the records support a score of 4. The patient had poor response to treatment and recovery management as she had not achieved complete remission of symptoms or optimal control despite a treatment history including outpatient treatment, inpatient psychiatric hospitalizations, an intensive outpatient program (IOP), and a PHP. The patient had undergone several psychotropic medication trials with limited or no success. She repeatedly demonstrated evidence of innate vulnerability under stress. With regard to treatment acceptance and engagement, the records support a score of 3. The patient attended groups and activities and engaged in treatment but struggled at times with utilizing coping skills and isolating. 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 was medically monitored residence-based services. This is consistent with the level of care that the patient received at the RTC. In this patients case, RTC level of care was in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the services at issue were clinically appropriate in terms of type, frequency, extent, site, and duration. The services at issue were 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, (1) RTC services the patient received from Huntsman Mental Health Institute at the University of Utah were medically necessary for the treatment of this patient. 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 met the criteria for PHP services.With regard to risk of harm, the records support a score of 3. The patient had a significant risk of harm, due to a history of suicidal ideation with a plan. The records noted a history of suicide attempts and of self-harm. The records noted that the patient had been physically aggressive toward her mother and had a history of dysregulated behaviors. She had only recently begun to be able to keep herself safe, and during the period under review, did not engage in any unsafe behaviors. Thus, the patient has a total score of 21. In this case, the recommended level of care is medically monitored community-based services. This is consistent with the level of care that the patient received at the PHP. In this patients case, PHP level of care was in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the services at issue were clinically appropriate in terms of type, frequency, extent, site, and duration. The services at issue were 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. 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.