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

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for individual therapy services, two times a week. 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 meets the criteria for high intensity community-based services, which can take many forms and service delivery occurs two or more days per week. For dimension 1, the patient has been at some risk of harm (score 2). The records document that the patient required treatment in the emergency department in March 2022 for suicidal ideation and he was subsequently hospitalized. The patient has continued to express passive suicidal ideation. The patient does not have a history of suicide attempts or self-harm behaviors. The records document mild suicidal ideation with no intent or conscious plan and with no past history. For dimension 2, the patient has demonstrated moderate functional impairment (score 3) due to feeling overwhelmed by anxiety and unable to utilize skills because of overwhelming anxiety. The patient has panic attacks at school, and he has not attended school at times due to anxiety and depression. The patient lacks motivation. The patient has significant disturbances in physical function that do not pose a serious threat to health. For dimension 3, the patient has significant co-occurrences (score 3) given his history of migraine headaches, chronic acne, and insomnia. The patient reports that he has been sleeping only three to four hours per night due to insomnia due to anxious thoughts. The patients anxiety and depression can cause sleep disturbance and poor sleep can exacerbate depression and anxiety. Medical conditions are present that may adversely affect, or be adversely affected by, the presenting condition. For dimension 4A, the patients recovery environment is mildly stressful (score 2). The records document that the patient feels overwhelmed with school. The patient has expressed that he is a burden to his family. The patient has expectations for performance at home or school that create discomfort. For dimension 4B, the patients recovery environment provides limited support (score 3) since the patients mother advocates for the patients treatment. The patient is not close with his father. The patient was referred for wrap services but there is a wait list indicating that community resources only partially compensate for the patients unmet emotional needs. For dimension 5, the patient has shown moderate or equivocal resiliency and response to services (score 3) since prior treatment has included brief outpatient therapy, psychotropic medications, and an inpatient psychiatric hospitalization. The records document that previous 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 exhibited adequate engagement in services (score 2). The provider charted that the patient is overwhelmed by anxiety and unable to use skills. The patient is unwilling to participate in an IOP or PHP due to social anxiety, but he has expressed willingness to meet individually with a provider. 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 3 high intensity community-based services. Per CALOCUS-CASII, treatment intensity of clinical services at Level Three occurs two or more days per week. 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, the requested individual therapy services, two times a week 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.