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

Findings:  The physician reviewer found that The patients parent has requested reimbursement for residential treatment center (RTC) services. 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 met the criteria for RTC services.For dimension 1, the patient was at serious risk of harm (score 4) due to a history of aggression toward family members which have required police intervention. The patient denied suicidal ideation and homicidal ideation. The patient exhibited unsafe behaviors while in RTC. The records indicate a history of impulsivity and explosive behaviors. The patient has a long history of demonstrating clear and persistent inability to maintain physical safety and use the environment for safety. For dimension 2, the patient demonstrated moderate functional impairment (score 3) due to the ongoing struggles in social relationships with family, peers, and treatment providers. While in RTC, the patient often misperceived or misinterpreted the behaviors of others. The patient continued to struggle with procrastination and time management issues. The records document that the patient had chronic and/or variably severe deficits in interpersonal relationships, but with ability to engage in socially constructive activities. For dimension 3, the patient had significant co-occurrences (score 3) given developmental disability and several mental health diagnoses. The patient also has chronic constipation. Research has shown that constipation is a risk factor for behavioral changes and aggression in young patients with developmental disabilities. The records support that a medical condition was present that may adversely affect, or be adversely affected by, the presenting condition. For dimension 4A, the patients recovery environment was highly stressful (score 4) due to the patients anger dyscontrol and  aggressive behaviors in the home. The patients behavioral issues in the home have required police intervention on multiple occasions. The patient has received ample mental health treatment due to behaviors. There is evidence of serious disruption of family milieu. For dimension 4B, the patients recovery environment provided limited support (score 3) considering that the patients parents were supportive as evidenced by the patients extensive treatment history. However, community resources only partially compensated for the patients unmet emotional needs as evidenced by repeated treatment in RTC and recent diagnosis of autism. For dimension 5, the patient has shown negligible resiliency and response to services (score 5). The patients past mental health treatment is extensive and includes multiple stays in RTC level of care. The patient continued to struggle while in the RTC. The patients symptomatology has persisted despite multiple treatment attempts at various levels of care. The records document that past response to treatment has been quite minimal, even when treated at high levels of care for extended periods of time. For dimension 6, the patient showed limited engagement in treatment (score 3). The records document that the patient lacked consistent insight and often minimized contribution to problems but was willing to engage with providers. However, at times, the patient became reactive when given feedback or disengaged for no apparent reason. The patient often blamed others for personal problems. The patient minimized or rationalized distressing behaviors and consequences. These findings give the patient a composite score of 25, which is consistent with Level 5 medically monitored residence-based services. Per CALOCUS-CASII, the patients scores of 4 for risk of harm also supports treatment with Level 5 medically monitored residence-based services level of care. For these reasons, the psychiatric RTC services were medically necessary for treatment of this patient.Final Result: The reviewer determined that the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.