Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 

The patient is a 15-year-old female with a past psychiatric history of mild intellectual disability, major depressive disorder, attention deficit/hyperactivity disorder, disruptive mood dysregulation disorder, oppositional defiant disorder, reactive attachment disorder, unspecified anxiety disorder, and unspecified neurodevelopmental disorder (in utero exposure to methamphetamine). The patientas parent has requested reimbursement and prospective authorization and coverage for residential behavioral health level of care from 3/12/21 forward. The Health Insurer has denied this request and reported that the services at issue were not and are not medically necessary for the treatment of this patient. This denial is the subject of this appeal and determination. The physician reviewer found that 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 did not meet the criteria for residential behavioral health level of care from 3/12/21 forward.
In terms of risk of harm, the records support a score of 3. This dimension assesses potential for harm to self or others, or having harm inflicted upon them. The patient has a history of suicide attempts (cutting with the intent to die and attempting to overdose) and other self-endangering behaviors (laying on a road). She has been placed on psychiatric holds on three separate occasions since August 2020. During the period under review, records note that the patient engaged in assaultive behavior towards staff, threatened a peer, and engaged in self-harm behaviors. The patient has not endorsed any suicidal or homicidal ideation. This is indicative of significant risk of harm. In terms of functional status, the records support a score of 3. This dimension assesses the degree to which a person is able to fulfill responsibilities within developmental constraints. According to records, the patient struggles in her relationship with peers and staff at times. She has been attending school and has done well. Her behavior is most consistent with moderate functional impairment. In terms of co-occurring developmental, medical, substance use and psychiatric conditions, the records support a score of 3. This dimension assesses the coexistence of disorders across four domains (psychiatric, substance use, medical or developmental) that may complicate the course of treatment. The patient has significant co-occurrence considering her psychiatric diagnoses and comorbid mild intellectual disability and neurodevelopmental disorder. In terms of level of stress of the recovery environment, the records support a score of 3. This dimension assesses the stressors in the environment, social circumstances, and interpersonal relationships. The patientas recovery environment appears to be moderately stressful due to struggles in her relationships with family, peers, and staff. In terms of level of support of the recovery environment, the records support a score of 2. This dimension assesses the presence of family and social support to augment the recovery environment. The patientas recovery environment is supportive. Her parents and providers appear to be actively involved in supporting her. In terms of resiliency and response to services, the records support a score of 4. This dimension assesses how past experiences with treatment and recovery might indicate how the patient might respond in the future. The patient has shown poor response to treatment and recovery management. Previous treatment has included various forms of outpatient psychotherapy, outpatient psychiatric treatment with multiple medication trials, Wrap Around services, brief inpatient psychiatric treatment, and wilderness treatment. The patientas symptomatology has persisted despite multiple treatment attempts at various levels of care. In terms of engagement of the child or adolescent, the records support a score of 3. The child and adolescent sub-dimension assesses the ability to form therapeutic relationship within developmental constraints. The records indicate that the patient attended therapy appointments, but there were instances in which she was avoidant during individual therapy sessions, did not complete therapeutic assignments, did not engage in groups, left family sessions early, or struggled with aopenness to alternative perspectives.a This is consistent with limited engagement. These findings give the patient a composite score of 21, which is consistent with Level 4, Medically Monitored Community Based Services. Therefore, residential behavioral health level of care from 3/12/21 forward were not and are not medically necessary for the treatment of this patient.