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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for weekly therapy that includes eye movement desensitization and reprocessing (EMDR), dialectical behavior therapy (DBT), and cognitive behavioral therapy (CBT). The American Academy of Child and Adolescent Psychiatry (AACAP) and American Association of Community Psychiatrists (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 provides a reliable framework for determining the appropriate level of care for adolescents needing mental health treatment. 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) developmental, medical, substance use and psychiatric comorbidity; (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 meets the criteria for the requested weekly therapy services with EMDR, DBT and CBT modalities. For dimension 1, the patient is at some risk of harm (score 2) due to lack of documented current or past suicidal ideation. The provider noted that the patient is in continued remission of PTSD-related self-harming behaviors, which supports a past history of self-harm. The records document recent self-harm. There is indication or report of occasional impulsivity with minimal consequences for self or others. For dimension 2, the patient has demonstrated moderate functional impairment (score 3) since the provider has described the patients condition as currently stable and improving. The patient has also endorsed improvement in her activities of daily living with ability to go on a job interview and become more social. The provider noted that the patient recently with through a break up and has conflict with father. The records note that recent gains and stabilization in function have been achieved while participating in treatment in a structured, protected, or enriched service. For dimension 3, the patient has no co-occurrence of conditions (score 1). The records document that no co-morbidities are reported. There is no evidence of medical illness, substance abuse, developmental disability, or psychiatric disturbances apart from the presenting condition. For dimension 4A, the patients recovery environment is mildly stressful (score 2). The records indicate that the patient has work, school, and interpersonal stressors. Overall, expectations for performance at home or school that create discomfort. For dimension 4B, the patients recovery environment is supportive (score 2) as evidenced by his sisters participation in a therapy session and patient utilization of a therapist. The patients family is willing and able to participate in treatment if requested to do so and have capacity to effect needed changes. For dimension 5, the patient has exhibited moderate or equivocal response to services (score 3) since prior treatment has been limited to outpatient psychotherapy, which was helpful in achieving stability, but has not achieved complete remission or optimal control of symptoms. Previous experience in treatment at low level of intensity has not been successful in relief of symptoms or optimal control of symptoms. For dimension 6, the patient has shown adequate engagement in services (score 2). The records indicate that the patient has been positively engaged in treatment. There is evidence that the patient is able to develop a trusting, positive relationship with clinicians and other care providers. These findings give the patient a composite score of 15, which is consistent with Level 2 low intensity community-based services. According to CALOCUS Levels of Care Descriptions, Level 2 clinical services should be available up to two hours per week but usually not less than one hour every four weeks. The specific modalities requested are also supported as medically necessary. The patient is still considered an adolescent, for which DBT is an appropriate treatment for her self-harm behaviors. EMDR, CBT, and DBT are evidence-based therapeutic interventions and are appropriate in treating this patients mental health issues. EMDR is a form of therapy commonly used to treatment symptoms of trauma and PTSD. Both EMDR and CBT are trauma-focused therapies, which clinical trials and meta-analysis have found to be effective in treating PTSD and those experiencing the effects of trauma. CBT is also an evidence-based intervention for treating a variety of anxiety disorders. In addition, DBT is first-line treatment for non-suicidal self-harm behaviors in adolescents. Moreover, the requested services 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, weekly therapy that includes EMDR, DBT, and CBT is medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested services 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.