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) 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/meets the criteria for the mental health RTC services. For dimension 1, the patient has been at serious risk of harm (score 4). The records document that on admission, the patient endorsed suicidal ideation with plan to overdose on acetaminophen. While in the RTC, the patient stated that she is not safe to go home due to suicidal ideation and self-harm behaviors. The patient has endorsed suicidal ideation with a desire to pass away in her sleep. The provider charted that the patient has engaged in self-harm behaviors during her admission. The patient has endorsed use of alcohol and cannabis. Overall, the records document current suicidal ideation with clear, expressed intentions or a past history of carrying out such behavior. For dimension 2, the patient has demonstrated moderate functional impairment (score 3) due to inability to attend school due to anxiety and panic. The patient has missed school due to her psychiatric symptoms and she has been socially isolating. During the period under review, she exhibited significant mood lability intermittently. The patients school behavior has deteriorated to the point of the patient has faced some school disciplinary action and is at risk for placement in an alternative school program. The absenteeism may be sporadic.  For dimension 3, the patient has minor co-occurrence (score 2) given the use of alcohol and cannabis. The patient also struggles with insomnia. The records document occasional, self-limited episodes of substance use that show no pattern of escalation, with no indication of adverse effect on functioning or the presenting condition. For dimension 4A, the patients recovery environment has been highly stressful (score 4) considering the patients struggles in her relationship with her father and longstanding conflict between her parents, who are divorced. The provider noted that family conflict was evident in family therapy sessions. The patient is described as enmeshed with her mother and reports having to take care of her mom since she struggles with mental health as well. The patient also reports feeling stressed by school. There is report of serious disruption of family milieu. For dimension 4B, the patients recovery environment has provided limited support (score 3). The records document that the patient identifies her mother, sister, and several friends as supportive. However, the relationship between the patient and her mother is enmeshed and her father has shown limited in his ability to appropriately respond to the patients needs. The patients family demonstrate only partial ability to make necessary changes during treatment. For dimension 5, the patient has exhibited poor resiliency and response to services (score 4). The patient has previously been treated with outpatient treatment, two intensive outpatient programs, and multiple psychotropic medication trials. Developmental pressures and life changes have created episodes of distress. There is documentation that previous treatment has not achieved optimal control of symptoms and patient exhibits poor resilience and poor response to treatment. For dimension 6, the patients parents have shown limited engagement in treatment (score 3) due to inability to positively engage in the patients treatment. The patients father has not been open to redirection at times, has talked over the providers, and struggles to utilize feedback about how to best support the patient. The records document inability to participate consistently in treatment, with inconsistent follow-through. These findings give the patient a composite score of 23, 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. Moreover, the RTC services were and 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. For these reasons, the mental health residential treatment center (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. 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.