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

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) level of care. Findings:  The physician reviewer found thatAmerican 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 meets the criteria for RTC servicesWith regard to risk of harm, the records support a score of 4. The patient has a serious risk of harm, due to multiple suicide attempts, most recently shortly after being admitted to an RTC, and self-harm behaviors since admission to RTC. The patient continued to endorse suicidal ideation at the RTC. The records noted a history of impulsivity and that the patient exhibits poor judgment and insight. In terms of functional status, the records support a score of 4. The documentation noted serious functional impairment due to problems with social interactions secondary to autism spectrum disorder. The records noted that the patient has difficulty with recognizing social cues, exhibits concrete thinking, and has difficulty regulating his emotions. The patient reports struggling  to connect with peers due to cultural differences. The patients father reports that patient pushes other aggressively with words to end the relationships and berates them, suggesting consistent conflict and/or disrupted interactions with others. With regard to comorbidity, the records support a score of 3. The patient had significant comorbidity, due to the presence of attention deficit hyperactivity disorder (ADHD) and autism, neurodevelopmental disorders that adversely affect his ability to regulate his mood, along with asthma for which he is prescribed an inhaler. In terms of level of stress of the recovery environment, the records support a score of 3. The patient had a moderately stressful environment as he reports cultural differences that contribute to his difficulties connecting with peers, a source of stress to the patient. The patient appears to be easily overwhelmed. School is a source of stress as patient has not been as academically successful as he would like to be, becoming suicidal after being stepped down to a lower-level algebra class. With regard to level of support of the recovery environment, the records support a score of 3 as his family is supportive. However, the records did not note an Individualized Education Plan (IEP) at school to provide accommodations for ADHD and/or autism. In terms of resiliency and treatment history, the records support a score of 4. The patient has poor response to treatment and recovery management as prior treatment has included outpatient psychotherapy and psychiatric treatment, PHP, RTC, and inpatient psychiatric hospitalizations. With regard to treatment acceptance and engagement, the records support a score of 3. The patient has been participating in individual and group therapies, but has struggled to consistently utilize coping skills when distressed and resorted to engaging in self-harm. Thus, the patient has a total score of 24. The records support a 4 in terms of risk of harm and functional status. In this case, the recommended level of care is medically monitored residence-based services. With the functional impairment and elevated risk of harm noted, the patient meets CALOCUS 5b extended stay criteria. This is consistent with the level of care that the patient received and is receiving at the RTC. In this patients case, RTC level of care was and is in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the services at issue were and are clinically appropriate in terms of type, frequency, extent, site, and duration. The services at issue were not and are 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, RTC level of care services were and are medically necessary for the 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.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.