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

Findings:  The physician reviewer found that The patients parent has requested reimbursement and prospective authorization and coverage 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 meets the criteria for RTC services.For dimension 1, the patient has been at significant risk of harm (score 3) due to lack of suicidal ideation, but with urges to self-harm but the patient has not been acting on those urges. The patient has a history of bingeing and purging, losing weight while in treatment, and over-exercising. The patient endorses a fear of various foods and of gaining weight. The patient has been eating while in treatment and denies bingeing and purging. In addition, the patients sobriety from substances is recent. The records support periods of inability to care for self and maintain physical safety in developmentally appropriate ways. For dimension 2, the patient exhibits moderate functional impairment (score 3) as evidenced by troubled relationships with both parents, recent breakdown with screaming and panic symptoms after a peer confrontation, and difficulty managing reactivity, emotional lability, irritability, and sadness. The patient reported continued high levels of anxiety. There is evidence of recent gains and stabilization in functioning achieved while participating in treatment in a structured, protected, and enriched service. For dimension 3, the patient has major co-occurrences (score 4) considering psychiatric diagnosis of bulimia nervosa which has led to vital sign instability. Furthermore, bulimia can cause electrolyte abnormalities which can have cardiac sequelae. The patients body habitus is described as extremely thin and almost skeletal. The patient also has two severe substance use disorders. The records document that psychiatric symptoms are present that clearly impair functioning, persist in the absence of stressors, and seriously impair recovery from the presenting condition.For dimension 4A, the patients recovery environment has been moderately stressful (score 3) due to recent deterioration of family relationships. The patient has a conflictual relationship with the father and the mother appears to lack an emotional connection with the patient. The patients boyfriend is not supportive of mental health treatment and does not want to have contact with him. The records support the presence of disruption of family and social milieu. For dimension 4B, the patients recovery environment provides limited support (score 3). The provider noted that the patients father is described as judgmental but willing to learn how to improve his insight. The patients mother is described as detached, but does participate in group sessions, and presented with lack of emotional connection to the patient. The patients family or primary caretakers demonstrate only partial ability to make necessary changes during treatment. For dimension 5, the patient has shown moderate or equivocal resiliency and response to services (score 3). The records document that previous treatment has included outpatient mental health treatment consisting of psychotherapy, psychiatric care, and psychotropic medications. Previous experience in treatment at low level of intensity has not been successful in achieving relief of symptoms or optimal control of symptoms. For dimension 6, the patient has shown limited engagement (score 3) given difficulty discussing the eating disorder with the care providers. The patient has lost four pounds since admission. Although the patient has not been bingeing and purging since admission, the patient has been exercising. The patient acknowledges the existence of a problem, but resists accepting even limited age-appropriate responsibility for development, perpetuation, or consequences of the problem. These findings give the patient a composite score of 22, which is consistent with Level 4 medically monitored community-based services. However, per CALOCUS-CASII, the patients score on co-occurrence supports treatment at Level 5 medically monitored residence-based services. Moreover, the RTC 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. Accordingly, the RTC services were and are medically necessary for treatment of this patient.Final Result: The reviewer determined that the services at issue were and are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.