Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer  
 
The patient is an 18-year-old male who presented for a psychiatric evaluation on 9/21/21. The 
patient has requested reimbursement for RTC inpatient facility from 10/18/21 through 8/11/22. 
The Health Insurer has denied this request and reported that the services at issue were not 
medically necessary for the treatment of this patient. 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, the patient met the 
criteria for RTC services from 10/18/21 through 3/24/22. With regard to risk of harm, the records 
support a score of 4. The patient had a serious risk of harm due to a history of suicidal ideation, 
self-harm behaviors, and a past suicide attempt. At the time of admission to RTC, the patient 
denied suicidal ideation but reported passive suicidal ideation two days prior to admission. The 
patient continued to endorse suicidal ideation in December 2021 which he attributed to being in 
residential treatment. In terms of functional status, the records support a score of 4. The 
documentation  noted serious functional impairment  due to  serious deterioration.  Prior to 
admission, the patient endorsed overwhelming anxiety and depression, was struggling in school, 
and struggled in social interactions with peers. He presented as disheveled. With regard to 
comorbidity, the records support a score of 3. The patient had significant comorbidity, due to the 
presence of a neurodevelopmental disorder, ADHD. His developmental disability may adversely 
affect the presenting condition and/or may require significant augmentation of alteration of 
treatment for the presenting condition, or adversely affect the presenting condition. In terms of 
the level of stress of the recovery environment, the records support a score of 3. The patient had 
a moderately stressful environment. The records noted that the patient was bullied in middle 
school but denied this as a source of trauma. The records noted that the patient reported 
isolating and had difficulty interacting with peers. Role expectations appeared to exceed the 
patients capacity given his age, status, and developmental level. With regard to the level of 
support of the recovery environment, the records support a score of 3. The records suggest that 
the patients parents were supportive, and he had supportive outpatient treatment providers. 
However, community resources appeared to only partially compensate for the patients unmet 
emotional needs and/or the patient had limited or inconsistent access to network. This is 
consistent with limited support in the environment. In terms of resiliency and treatment history, 
the records support a score of 5. The patient had negligible resiliency and/or response to 
treatment as prior treatment included outpatient psychotherapy and psychiatric care including  psychotropic medication, PHP, and several inpatient psychiatric hospitalizations. The patients 
symptoms were persistent, and he showed no significant improvement in functional ability 
despite intensive treatment exposure. The patients past response to treatment has been 
minimal, even when treated at high levels of care for extended periods of time. With regard to 
treatment acceptance and engagement, the records support a score of 3. While the patient 
eventually engaged in treatment, as of February 2022 the patient was focused on returning 
home, suggesting limited engagement. Thus, the patient had a total score of 25. The records 
support a 4 in terms of functional status and risk of harm. In this case, the recommended level of 
care was medically monitored residence-based services. With the functional impairment and 
elevated risk of harm noted, the patient met CALOCUS 5b extended stay criteria from 10/18/21 
through 3/24/22. Therefore, RTC inpatient facility from 10/18/21 through 3/24/22 was medically 
necessary for the treatment of this patient. Applying the CALOCUS-CASII framework, this patient 
did not meet the criteria for RTC services from 3/25/22 through 8/11/22. With regard to risk of 
harm, the records support a score of 3. The patient had a significant risk of harm due to a history 
of suicidal ideation, self-harm behaviors, and a past suicide attempt. At the time of admission to 
RTC, the patient denied suicidal ideation but reported passive suicidal ideation two days prior to 
admission. The patient continued to endorse suicidal ideation in December 2021 which he 
attributed to being in residential treatment. However, individual therapy notes from 1/26/22 
through August 2022 did not indicate suicidal ideation. In terms of functional status, the records 
support a score of 3. The documentation noted moderate functional impairment due to serious 
deterioration. Notes reported that the patients functioning in the milieu, school and community, 
was above reproach. He was consistently observed as happy, helpful, energetic, and enthusiastic, 
however, his affect and demeanor changed in the presence of clinical or administrative staff. 
With regard to comorbidity, the records support a score of 3. The patient had significant 
comorbidity, due to the presence of a neurodevelopmental disorder, ADHD. His developmental 
disability  may  adversely  affect  the  presenting  condition  and/or  may  require  significant 
augmentation of alteration of treatment for the presenting condition, or adversely affect the 
presenting condition. In terms of the level of stress of the recovery environment, the records 
support a score of 3. The patient had a moderately stressful environment. The records noted that 
the patient was bullied in middle school but denied that this was a trauma. The records noted 
that the patient reported isolating, and had difficulty interacting with peers. Role expectations 
appear to exceed the patients capacity given age, status, and developmental level. With regard 
to the level of support of the recovery environment, the records support a score of 3. The records 
suggest that the patients parents are supportive, and he has supportive outpatient treatment 
providers.  However,  community  resources  appear  to only  partially compensate  for  unmet 
emotional needs and/or the adolescent had limited or inconsistent access to network. This is 
consistent with limited support in the environment. In terms of resiliency and treatment history, 
the records support a score of 5. The patient had negligible resiliency and/or response to 
treatment  as  prior  treatment  has  included  outpatient  psychotherapy  and  psychiatric  care 
including psychotropic medication, PHP, and several inpatient psychiatric hospitalizations. The 
patients symptoms were persistent, and he showed no significant improvement in functional 
ability despite intensive treatment exposure. The patients past response to treatment has been 
minimal, even when treated at high levels of care for extended periods of time. With regard to 
treatment acceptance and engagement, the records support a score of 2. As of 3/25/22, the  patient appeared to be adequately engaged in treatment.  Thus, the patient has a total score of 
22. In this case, the recommended level of care was medically monitored community-based 
services. This is consistent with the level of care that the patient received at the residential 
treatment center. Therefore, RTC inpatient facility from 3/25/22 through 8/11/22 were not 
medically necessary for the treatment of this patient.