Appeal type: Medical Necessity
Decision: Upheld 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) 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 does not meet the criteria for RTC services.For dimension 1, the patient was at some risk of harm (score 2) due to a history of suicidal ideation and self-harm. The patient denies intention of acting on suicidal thoughts or working out details of how to commit suicide. The records document past history of fleeting suicidal ideation with no current ideation, plan, or intention and no significant distress. For dimension 2, the patient has shown moderate functional impairment (score 3) given her loss interest in previously enjoyed activities, isolation  from friends and family, and loss of eight pounds over the past few months. The patient endorses amotivation and her grades have declined. She is noted to be verbally aggressive towards parents and has become increasingly oppositional and defiant. There is evidence of conflicted, withdrawn, or otherwise troubled relationships with peers adults, and/or family, but without episodes of aggression. For dimension 3, the patient has significant co-occurrence (score 3) due to longstanding insomnia and loss of weight in the preceding months. The patients sleep difficulties can exacerbate depression and anxiety and psychiatric disorders can exacerbate sleep issues. Thus, medical conditions are present that may adversely affect, or be adversely affected by, the presenting condition. For dimension 4A, the patients recovery environment has been moderately stressful (score 3). The records document that the patient has a conflictual relationship with her mother with whom she feels is aggressive and accusatory. Her father consumes alcohol daily. The patient has been suspended from school. There is documentation of disruption of family and social milieu. For dimension 4B, the patients recovery environment has been supportive (score 2) given her parents support although the patient does not view them as supportive. The patient identifies her friends as supportive. The patients family/primary caretakers and willing and able to participate in treatment of requested to do so and have capacity to effect needed changes. For dimension 5, the patient has exhibited moderate or equivocal resiliency and response to services (score 3) since previous experience in treatment at low level of intensity has not been successful in relief of symptoms or optimal control of symptoms. Prior treatment is minimal and includes two months of outpatient psychotherapy. However, the patient has exhibited equivocal capacity to deal with stressors and maintain normal development. For dimension 6, the patient has shown adequate engagement in services (score 2) due to her providers reports that she appears adequately engaged in treatment as evidenced by her participation in groups and individual therapy. The patient has been able to develop a trusting, positive relationship with clinicians and other care providers. These findings give the patient a composite score of 18, which is consistent with Level 2 high intensity community-based services. In addition, the RTC services were not and are not in accordance with the generally accepted standards of mental health and substance use disorder care, or clinically appropriate in terms of type, frequency, extent, site, and duration. Given these findings, the RTC services were not and are not medically necessary for treatment of this patient.  Final Result: The reviewer determined that the services at issue were not and are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in psychiatry with subspecialty 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.