Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer  
 
The  patient  is  a  13-year-old  who  was  admitted  to  a  residential  treatment  center  following 
hospitalization for depression, suicidality, and self-harm. The patients parent has requested 
reimbursement for residential treatment center services provided from 4/26/21 through 6/15/21. 
The Health Insurer has denied this request and reported that the services at issue were not medically 
necessary  for  the  treatment  of  this  patient.  This  denial  is  the  subject  of  this  appeal  and 
determination. 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, this patient met the criteria for residential 
treatment center services provided from 4/26/21 through 6/15/21. With regard to dimension I, risk 
of harm, the records support a score of 4. Just prior to 4/26/21 admission to the residential treatment 
center, the patient was taken to the emergency department on 4/12/21 after overdosing on blood 
pressure pills, Tylenol, and ibuprofen, with indications of ongoing suicidal ideation. The patient 
also was self-harming via superficial scratches. The patient has demonstrated a long history of 
reactivity and poor impulse control, with gender identity struggles, placing the patient at risk for 
suicide during this time period.  With regard to dimension II, functional status, the records support 
a score of 4. The patient has had serious deterioration of interpersonal interactions with consistent 
conflict  or  otherwise  disrupted  interactions  with  others,  including  impulsive  and  abusive 
behaviors. The patient appeared to be oppositional, irritable, anxious and depressed, with poor 
communication patterns with their mother. The records documented a poor ability to accept 
boundaries. In terms of dimension III, co-occurrence of conditions: developmental, medical, 
substance  use  and  psychiatric,  the  records  support  a  score  of  3.  The  patient  demonstrated 
significant  psychiatric  signs  and  symptoms  that  persisted  chronically  and  appeared  to  be 
moderately to severely debilitating, adversely affecting their ability to be safe in the community. 
The patient was also diagnosed with generalized anxiety disorder and gender dysphoria. With 
regard to dimension IV, sub-scale level of stress of the recovery environment, the records support 
a score of 3. The patient has been in an open adoption, with ongoing concerns around attachment 
issues and conflicts with their adoptive mother. The patients mother appears to have challenges 
with managing the degree of anxious distress that the patient has exhibited over the years. With 
regard to dimension IV, sub-scale level of support of the recovery environment, the records support 
a score of 3. Overall, the patients mother seems to have had had limited ability to respond 
appropriately to the patients developmental needs and/or problems or is ambivalent toward 
meeting these needs or addressing these problems. In terms of dimension V, resiliency and 
response to services, the records support a score of 4. The patient has demonstrated frequent  evidence of innate vulnerability under stress and difficulty resuming progress toward the expected 
developmental level. Despite the familys efforts to assist, the patient has struggled chronically 
with mood and behavioral issues. While at the residential treatment center, the patient continued 
to demonstrate struggles with implementing positive change, continuing to endorse anxiety, poor 
sleep, and challenges with taking responsibility. In terms of dimension VI, engagement in services, 
the records support a score of 3. It appears as if the patient tended to have ambivalent and 
distrustful relationships with clinicians and other care providers and at times reported not feeling 
validated by their therapist or mother. The patient appeared to have a number of treatment 
interfering behaviors, with challenges in following through with agreed upon expectations. Thus, 
the patient has a composite score of 24. This score supports Medically Monitored Intensive 
Integrated  Services.  Therefore,  residential  treatment  center  services  provided  from  4/26/21 
through 6/15/21 were medically necessary for the treatment of this patient.